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Sun, 19 Jul 2015 17:22:00 +0000Sun, 19 Jul 2015 17:22:00 +0000hourly13600SnapPages.comAntibiotic Resistance - Why this is important to everyone nowMichael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2015/07/19/antibiotic-resistance-why-this-is-important-to-everyone-now
Sun, 19 Jul 2015 17:22:00 +0000http://MDAskMe.com/blog/2015/07/19/antibiotic-resistance-why-this-is-important-to-everyone-nowAntibiotic resistance is a problem that we have been aware of almost since penicillin was first developed. Its the natural outcome of natural selection when bacteria are exposed to antibiotics, but now we are facing a moment when resistance may disarm even our newest and best antibiotics leaving us vulnerable to infections once again.

In the pre-antibiotic era infections were the most common cause of death. Pneumonia, Tuberculosis, and even infections from minor wounds were beyond the help of physicians. Even something as simple as strep throat could result in injury to the heart and death. Antibiotics changed that so successfully that people today forget what it was like to live in fear of even a small cut or fever. In 1900 Tuberculosis was the second leading cause of death in the U.S. yet only yesterday when I mentioned that I had to test a young woman for tuberculosis her response was "whats's that?". Antibiotics have been that successful.

Antibiotics have turned once deadly diseases into minor nuisances but they have been over used to the point that some of those bacteria are once again beyond the reach of modern medicine. New antibiotics have been developed but we are at a disadvantage. At most there may be a few thousand scientists around the world working on new antibiotics and it takes many years to discover, test, and bring a new antibiotic to market. Those physicians and scientists can only work so many hours. They need to sleep and eat and even occasionally take some time off. But there are trillions of bacteria working on defeating our efforts. They never get tired. They never go home, and they are willing to die for their cause by the billions to produce just one successful offspring who can defeat us and then multiply to produce trillions of its own offspring to spread this new drug resistant trait around the world. We reproduce every 20 years. They reproduce every 20 minutes. We are massively outnumbered and outgunned.

So why did this happen? Some level of antibiotic resistance was inevitable. In fact there were antibiotic resistant bacteria before we even knew what an antibiotic was. Most antibiotics are derived from molecules that bacteria use to attack other bacteria. In this battle for supremacy among bacteria the bacteria which were under attack developed defenses against these weapons. When man discovered these molecules which we call antibiotics, there were already some bacteria in the world that had genes which made them resistant to the effects of these drugs, but they were relatively few in number.

Once we started using antibiotics routinely thousands of species of bacteria that normally reside in our bodies would occasionally get exposed to these drugs. Most would be killed but some would have the resistance gene which would allow them to survive and multiply to become the predominant bacteria. Natural selection would allow the resistant bacteria to survive and pass on their genes to the next generation. Although humans and other animals can only pass genes to their offspring, bacteria can pass genes on to other bacteria and even to bacteria of other species. For this reason antibiotic resistance can travel quickly within and between different types of bacteria once it is established.

Antibiotic resistance has probably been around for billions of years but it wasn't a big problem until the past few decades. There are several reasons why antibiotic resistance has become so widespread.

Use of antibiotics in livestock - 80% of all antibiotics manufactured are used to fatten perfectly healthy livestock. This encourages the rise of resistant organisms which then enter the food chain and our bodies.

Unnecessary use of antibiotics in people - Many of the antibiotic prescriptions written for people are written for illnesses that will not respond to antibiotics. As mentioned above, this encourages antibiotic resistance to develop among the bacteria that live harmlessly in and on our body and these bacteria may later pass that resistance gene on to bacteria which are causing an infection.

There is a lot people can do to help stem the wave of drug resistant bacteria.

Look for meats and fish that say they are antibiotic free or grown without antibiotics

Encourage your legislator to push for laws to reduce the use of antibiotics in livestock and fish and to prevent the importation of such products. Let them know this is important to you.

Ask your physician if the antibiotic prescription they are writing is necessary or if its instead possible to take a more conservative approach and only use the antibiotic if the condition worsens.

Don't pressure your physician to give you an antibiotic. Many prescriptions are written for things like colds and other viral illnesses which will not respond to an antibiotic because the physician feels its easier to just write the prescription than to fight with a patient who wants the antibiotic. Some patients with colds will say "but I just can't afford to be sick". The virus doesn't care. It's not going to die in the presence of an antibiotic just because you can't afford to be sick.

Don't save or share unused antibiotics

Don't throw antibiotics in the garbage or toilet. Discard them by bringing them to the pharmacy to be destroyed

]]>http://MDAskMe.com/blog/2015/07/19/antibiotic-resistance-why-this-is-important-to-everyone-now#comments0Cancer Screening - What's new in the new recommendations?Michael Melgar, MDMichael Melgar, MDClick the following link below to read more about [...]]]>http://MDAskMe.com/blog/2015/05/20/cancer-screening-whats-new-in-the-new-recommendations
Wed, 20 May 2015 20:58:00 +0000http://MDAskMe.com/blog/2015/05/20/cancer-screening-whats-new-in-the-new-recommendationsClick the following link below to read more about this: Cancer Screening Guidelines

]]>http://MDAskMe.com/blog/2015/05/20/cancer-screening-whats-new-in-the-new-recommendations#comments0FOLD IT - You don't have to have a degree to make scientific discoveriesMmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2015/02/24/fold-it-you-dont-have-to-have-a-degree-to-make-scientific-discoveries
Tue, 24 Feb 2015 13:13:00 +0000http://MDAskMe.com/blog/2015/02/24/fold-it-you-dont-have-to-have-a-degree-to-make-scientific-discoveriesProteins are the most important molecules in our bodies. Proteins are the building blocks of every structure in your body. Specialised proteins form everything from enzymes, to hormones, receptors, and antibodies. The unique properties of proteins allow them to be formed into an almost infinite number of shapes allowing them to accomplish so many important tasks.

Proteins are built by linking amino acids together in a chain. The sequence of amino acids determines what the protein will be able to do. Our genes code for the exact sequence of amino acids required to make each protein that our body produces . We already know the exact amino acid sequence for many of the most important proteins but there is more to proteins than the two dimensional amino acid sequence. In order for proteins to do their job they have to fold into a three dimensional structure like the one depicted above. That's where things get a little difficult and where science and medicine needs your help.

As furtune would have it human beings happen to be extremely good at something computers can't do well at all. Human beings are good at recognizing patterns and manipulating three dimensional objects. That's where Fold It comes in. Fold it is a game that allows players to play around with the protein in an effort to find the correct folded structure.

You don't need to know anything about chemistry or biology to play this game. You just need a willingness to experiment and try new things. The game has a few simple rules that you need to follow. As you play with the structure you gain points depending on how well your folded protein fits the rules that the game has given you.

Since it was introduced fold it players have made real scientific contributions by discovering the proper folded structure of a number of proteins. Once scientists know how a protein is folded they can use that information to find the causes and cures for many important diseases.

From the time we are young we are tought that a normal temperature is 98.6. Most people would assume that something like 101 is therefor a fever and they would be correct, but when does the temperature become a fever as it rises from normal to 101?

First we need to discuss what a normal temperature is. While 98.6 is the often quoted number that is not completely correct. If we were to take the temperatures of 100 healthy people we would find that most would not be 98.6. A 1992 study of 148 adults showed that oral temperatures in healthy individuals can range from 96.0ºF to 100.8ºF with a average of about 98.2. Normal rectal temperatures are about 1.0ºF higher.

The study also found that the lowest temperatures were in the mornings around 6am with peak temperatures generally occuring around 6pm in the evening.

From these studies, a morning reading >37.2ºC (98.9ºF) or an afternoon temperature of >37.7ºC (99.9ºF) would be above average, but as you can see from Figure 1 above, there is a lot of variation from person to person so even normal healthy individuals can sometimes have a temperature of just under 101 and sometimes a sick individual will have a lower temperature. For this reason its important to take the temperature several times over the course of the day. Normally an individual's temperature varies by about 1ºF during the course of a day but when ill the temperature might vary by twice as much.

The standard medical definition of a fever is a temperature of 101 or more but obviously this has to be used as only a rough guide. When we say that someone has a fever what we are really saying is that their temperature is higher than normal, but what is normal varies depending on the time of the day and the person who's temperature we are taking.. The reason we want to know if someone has a fever is because it can be a clue to whether the person is ill and also because a temperature that is too high can be dangerous at times.

Fevers can have several causes. The great majority of fevers are caused by infections but there are occasional other causes.

Vaccines - Some people will develop a mild fever for a day or so after vaccination

Inflammatory conditions such as rheumatoid arthritis

Burns

Damage to the hypothalamus - very rare

Thats a good question actually. Why do we get a fever? The best answer at the moment is that we don't really know. We know how it occurs, but not exactly why. Some experts believe that fever is part of the body's defense mechanism against infection since viruses and bacteria may not be able to function and reproduce as well if the body is too warm. This seems logical since many enzymes work best in only a narrow temperature range and enzymes are important for many cellular functions that viruses and bacteria depend on in order to reproduce and metabolize. If this were true we would expect people to be sicker longer if they took measures to lower their body temperature but this is not the case. Taking Tylenol or Ibuprofen does not seem to prolong or worsen the outcome for most illnesses. For the moment its not clear whether a fever is an adaptation by the body to deal with the infection or just a necessary side effect that arises when our immune system goes to battle an infection, similar to the way our body heats up when we run or do other physical work. The heating up serves no purpose and can even be harmful. Its just the natural result when our muscles burn fuel and do work.

Sometimes I will hear a patient say. "It doesn't make any sense. I feel hot but when I take my temperature its normal" or "I've been freezing but now I have a fever". It sounds odd but this actually is exactly what you would expect when you undertstand what's going on.

Lets say the body is trying to raise its temperature. How does it accomplish that? Well it does it the same way you would raise the temperature if you were trying to warm your house. You can either turn up the furnace or you can close the windows and insulate it better to keep the heat in. The same thing happens in your body. The only difference is that the body has to convince you to do these things even though it can't actually talk to you. It communicates with you by the only method it has. It makes you feel cold or hot. It does this by changing the internal thermostat in a gland called the hypothalamus. When you feel cold you naturally do things to try and get warm. You involuntarily start to shiver. When you shiver your muscles contract and relax vigorously generating heat (this is like turning up the furnace in your house). In addition you may put on a sweatshirt or dive under the blankets (This is the same as adding insulation to your home or closing the windows to keep the heat inside). So in response to feeling cold you generate more heat and do everything you can to hold onto the heat you are generating. In a little while the temperture begins to soar and you have a fever. You're freezing but your temperature is 101!

When its time to get your temperature down your body makes you feel hot. You stop shivering, peel off all the layers and maybe you even drink something cold. A little while later your temperature goes away. So now you feel hot but your temperature is normal.

This up and down fluctation in the temperature may happen several times during the day when you are sick especially if you are taking ibuprofen or tylenol to knock the fever down, but most of the time it follows the same cycle as when we are healthy. It tends to be lower in the morning and spikes in the evening hours. Sometimes people think their illness has gone away because the temperature is normal in the morning when they wake up only to be disappointed when the fever is back later that evening. This isn't a sign that anything is seriously wrong, its just the normal pattern we expect to see with any illness that causes fever. As the days go by and the illness begins to resolve the temperature will be less and less each evening until eventually there's no more fever even at night.

A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich.AUMackowiak PA, Wasserman SS, Levine MMSOJAMA. 1992;268(12):1578.

The flu season will be here soon and getting vaccinated is the best way to protect yourself from this serious illness, but influenza is not the only contagious disease that adults need to protect themselves from. Vaccines aren't just for children. Some illnesses require updated vaccines from time to time and other diseases are more common only in adulthood. For these reasons there are a number of vaccines adults need to be aware of and discuss with their doctor.

Many people don't get vaccinated because they didn't know they should, but more worrisome is the fact that uninformed celebrities and uneducated internet bloggers have spread misinformation about vaccines that they don't understand. This has caused fear and concern among people who aren't sure what to believe. Not surprisingly there is little controversy in the medical community. Vaccines save lives and getting vaccinated protects not only you but your family and friends.

To separate fact from fiction click the link below to our Vaccine web page for more information on adult vaccines. As always discuss any questions or concerns with your doctor.

]]>http://MDAskMe.com/blog/2014/11/26/vaccines-are-you-at-risk#comments0GMO's (Genetically Modified Organisms) - Are they truly "Frankenfoods" or our best hope for feeding a hungry world?Mmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2014/09/09/gmos-genetically-modified-organisms-are-they-truly-frankenfoods-or-our-best-hope-for-feeding-a-hungry-world
Tue, 09 Sep 2014 00:00:00 +0000http://MDAskMe.com/blog/2014/09/09/gmos-genetically-modified-organisms-are-they-truly-frankenfoods-or-our-best-hope-for-feeding-a-hungry-worldGenetically Modified Oragnisms (GMO's) have been in the news the past few years as activists in the U.S. and Europe have mounted a campaign to rid our diets of foods that have been altered using the new techniques of genetic engineering. Recently they have pushed for legislation to require labeling of all foods that contain GMO's

Opponents of GMO products believe that all foods should be labelled "GMO free" or "Contains GMO's" so consumers will know what they are buying. They believe its only logical and right to provide consumers with more information so that they can make informed decisions. The problem with this approach is that more information is really only useful when it makes us more knowledgeable. If the information in fact misinforms us then it is worse than no information at all. Labelling products that contain GMO's creates the false impression among consumers that these products may be less safe than products which don't contain them, otherwise why would the government require such labeling? But if you look at the facts, there is no evidence that GMO's are less safe than other foods and in most ways they are no different than the foods we have all been eating for centuries.

GMO's are not new. The term Genetically Modified Organism refers to the new techniques that scientisits have developed which allows them to transfer genes from one ogranism to another but humans have been modifying the genetic makeup of plants and animals using cruder techniques for thousands of years. Broccoli for example did not exist in nature before man came along and created it. Broccoli is a man made organism which was created by "genetically modifying" a member of the cabbage family over 2,000 years ago through selective breeding. Native tomatoes and corn similarly are nothing like the human modified versions we all consume today. Both of these foods existed in nature only as small barely edible versions of their current day selves before man began tinkering with them.

While the techniques our ancestors used to modify the genetic makeup of these foods are different from the techniques we are using today the end result is not much different. In both cases we are tinkering with the organisms genes so that they express traits which make the plant more useful or desireable. By doing this the plant may produce larger fruit or different flavors. We may change it so that it produces higher amounts of important nutrients like vitamins or proteins. In other cases we may transfer a useful trait from one plant to another so that an important food crop learns how to survive with less watering, or how to make its own fertilzer, or how to defend itself from pests so less pesticides are needed.

As an example, modern corn which is the result of hundreds of years of selective breeding has much bigger kernels with far more starch and sugar than native corn. More recent strains created through modern methods of genetic science have added qualities that allow them to survive drought and pests.

So whats the difference between the way our ancestors changed the genetic makeup of their foods and the way we do it today?

Selective Breeding and hybridizationFor thousands of years our ancestors used a technique called selective breeding to artificially alter their plants and animals. They would breed organisms and then select the ones with the desired traits and discard the others. Over time this process would produce the product they wanted. On a genetic level what was happening is that undesireable genes were being extinguished and desireable genes were being selected for. Crossing one desireable organism with another would sometimes bring new genes together creating hybrids that had never before existed with unique combinations of genes that might provide even more useful traits. This approach is somehwat hap hazard as the breeder has to work with existing genes or wait for new mutations to occur sponatenously. It can take decades or centuries to improve an organism this way and some traits may never be attainable through this random process. In addition, the random somewhat blind process in which selective breeding alters the genetics of an organism means that the new breed may contain genes and traits that are undesireable.

Modern Genetic Engineering TechniquesTodays techniques build on the work of our ancestors but are more precise and rely less on luck. Scientists can now identify genes that bestow useful traits to plants and with the use of sophisticated genetic engineering techniques they can transplant these genes into other organisms so that the new organism may acquire the desired trait.

For example a scientist may find a wild grass plant that is especially drought resistant. With a lot of hard work they may identify one or two genes that are responsible for the plants natural ability to survive with less water. Scientitst have tools that allow them to isolate the gene and then transplant it into the chromosome of a useful plant like wheat for example. Often the transfered gene may not work in the new organism so this process requires a great deal of trial and error. When it does work the new organism has acquired a trait that may allow farmers to grow more food per acre and may allow food production on land that was previously barren. In parts of the world where land is not as fertile or growing seasons are shorter these new traits can be critical to feeding the local population.

Modern methods are less haphazard and more direct than the older methods of selective breeding but the outcome is not that much different. We change the genetic makeup of an organism so that it is more useful in some way.

GMO's are not new

About half of all the foods consumed today contain genetically modified organisms including fruits , vegetables, cereals, and meats. Without this technology we would scarcely be able to feed a fraction of the worlds current population and those who could afford to feed their families would probably have to pay more to do so. GMO techniques have allowed us to create food plants that can survive in dryer and colder conditions and resist pests better than older varieties.

in recent developments scientists developed a new GMO potato that may actually be safer than unaltered potatoes. As they exist now when potatoes are fried the sugars in the potato interact with an amino acid called asparagine to form a chemical called acrylamide. Acrylamide has been shown to cause cancer in animals although research in humans is still incomplete. Using modern genetic technology scientists have developed a potato that produces less asparagine and as a result less acrylamide. In theory this potato should be less likely to cause health problems than non-GMO potatoes. Unfortunately because of the current public preceptions about GMO ingredients this potato has been rejected by retailers including McDonalds. This leaves consumers with less choice rather than more.

I am concerned that GMO labeling proponents aren't really interested in in giving us choices or "educating" the public in the traditional sense. They have a heartfelt belief that all GMO products are harmful despite a lack of evidence that this is true. Rather than trying to inform the public I believe their goal is to persuade people not to use these products. They know that if a product is labelled "GMO free" people who are unfamiliar with the term or the details of the debate will naturally begin to assume that GMO's are harmful. Why would anyone care if something were GMO free unless GMO's were harmful? The label does not simply impart information. It is an implied warning that products which use GMO's are unsafe. The proposed legislation to require GMO labeling is an effort by GMO opponents to get politicians to spread the fear for them through these new laws and end the debate before it ever gets started.

GMO opponents' concerns about GMO's have taken several forms

1) Allergies - There have been claims that GMO's can cause allergic reactions in some people and while this is true, so can strawberries and mangos made the old fashioned way. Any food is capable of causing allergies in some people. GMO's are no less likely to trigger allergies but they are also no more likely to cause allergies than any other food. Introducing a new protein into our foods always presents this risk but the same is true anytime a person consumes a new food for the first time whether its a GMO food or a non-GMO food.

2) GMO's are too new and haven't been tested enough? - Yes some of these foods are new but the same could be said for any new apple or tomato that is discovered or create through old fashioned techniques and no concern has ever been raised about those food items. GMO's are tested extensively by manufacturers for safety and quality. In additon the FDA has set up a voluntary consultation process to engage with the developers of genetically engineered plants to help ensure the safety of food from these products. This is not required with foods created through the more random process of selective breeding. GMO's have only very small changes made in their DNA. 99.99% of the DNA is unchanged. New organisms should be studied carefully before being released into the wild but only to the same extent that these rules are also applied to varieties produced by selective breeding or through importation from other parts of the world.

3) GMO's may be harmful to insects and other organisms inthe environment. - Some GMO's do have modifications allowing them to produce new proteins. Some of these proteins are harmful to insects and while they may harm useful insects as well as the destructive ones these plants do not require the use of insecticidal sprays which travel over a wider area and kill more insects. It is possible that these organisms may have unintended effects on important insects so we need to study such things before putting new GMO plants into widespread use but again, this should be done in a way that is consistent with past practices. On a daily basis we use pesticides and herbicides which have the potential for causing harm to the enivronment but we do so in a way that balances the risk with the benefits. This is the approach we need to take with GMO's rather than throwing the baby out with the bath water as many GMO opponents propose.

The bottom line is that any new organism can have qualities that cause allergic reactions or which may harm other organisms, but nature introduces new organisms and changes existing organisms all the time. Although nature does this more slowly it also does it in a random fashion with no safety testing at all. GMO's are created with a great deal of thought and testing so that these food items are as safe to eat as possible and the effect on the environment is minimized. Its understandable that we should expect new food items to be tested for safety and GMO's are the most highly tested of new food items on the market, but GMO opponents seem to want a guarantee of safety that would never be attainable for any food, not even the ones they eat every day without a second thought. Instead of fighting to have these products banned a more appropriate response might be to advocate for more testing and more independant testing of all new foods by whatever means they are created or imported so that we can all feel safe about the foods we eat.

If producers are required to label products containing GMO's many will find themselves forced to switch to food sources that do not contain these products because the public will believe incorrectly that GMO's are not safe. The result will be a reduction in food production, increased prices, more hunger, and no real benefit to anyone. The next time you hear a GMO activist refer to these foods as Frankenfoods look at a head of broccoli and compare it to a head of cabbage. If we're not afraid of that type of genetically modified food created 2,000 years ago by selecting completely random mutations then why are we afraid of an ear of corn that can withstand a dryer growing season because a scientist carefully added one or two genes whose properties we know well?

NOTE: By the way. That "Frankenfood" photo at the top may look like an alien vegetable but it was created the old fashioned way through selective breeding. We shouldnt judge a food by its appearance or by a meaningless label that is put on it.

]]>http://MDAskMe.com/blog/2014/09/09/gmos-genetically-modified-organisms-are-they-truly-frankenfoods-or-our-best-hope-for-feeding-a-hungry-world#comments0Cheap Drugs - How to stay healthy without putting your bank account on life support.Michael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2014/08/07/cheap-drugs-how-to-stay-healthy-without-putting-your-bank-account-on-life-support
Thu, 07 Aug 2014 00:00:00 +0000http://MDAskMe.com/blog/2014/08/07/cheap-drugs-how-to-stay-healthy-without-putting-your-bank-account-on-life-supportNot too long ago I met a new patient who had come to me after her previous doctor had retired. She was a very pleasant older woman who was retired herself and on a fixed income. She was relatively healthy but had a number of chronic medical conditions such as high blood pressure, high cholesterol, diabetes and an underactive thyroid that were well controlled with the use of six different medications which she took daily. During the visit she related that she did not always take her medications because the cost had gotten so high, amounting to more than $600 a month.

Modern medicine has worked miracles. People today can expect to live longer and better than ever before. We have drugs now that can cure infections that used to kill thousands, prevent hear attacks and strokes, cure cancer, and help diabetics live normal lives. But with all of this success and long life comes a cost. Medications can be expensive. The good news is that they don't always have to be. With a little planning a savvy consumer can often purchase the medicines they need for a fraction of the cost and stay healthy without hemorrhaging money.

So how can a smart consumer save money? There are a number of tools available to help us cut our medication bill down to size.

Generic Drugs

The first tool is no big secret. Its generic medications. Generic medicines have the identical active ingedient that the brand name has but often at a much lower price. The only difference between the two will be the shape and color of the pill and perhaps the binders that hold it together. Despite fears that generics will not work as well as the branded drug there is no scientific evidence to support this concern and in fact the FDA regulations require generics to have equivalent doses of the active ingredients. Some generic drugs are actually manufactured by the same company that makes the branded drug but they chaneg the look and repackage it without the brand name.

Use a Similar Drug if no generic drug is available

Even though some drugs may not be available in generic form they may be members of a class of very similar drugs and another member of that class may be available as a generic. "Statin" drugs are used to treat cholesterol. Most people are familiar with Crestor which is a newer statin. Crestor is not available in generic form but several other members of that class such as Zocor, Lipitor, Mevacor, and Pravachol are. With few exceptions, most patients can switch from Crestor to another statin and do just as well. The same is true for many blood pressure medications and diabetes medications as well as medicines used for other conditions

Switch Pharmacies to one that has a low cost Generic Drug Plan

Neighborhood pharmacies are more convenient but they don't always have the best prices. Both Target and Walmart have generic drug programs that cover a long list of common drugs. These drugs can be purchased at very low cost. For most drugs on these lists a 30 day supply is only $4 and a 90 day supply is $10 even even with no insurance. If you do have insurance its important to tell the pharmacy you do not want to use your insurance for these prescriptions otherwise you may actually be charged a copay which could be higher than the cash price or you may be told that you can not get a 90 day supply through your insurance plan. Just tell them you will be paying cash out of pocket for your medications if the medicine is on their Generic Drug Formulary. Click on the links below to see if your medications are on these lists. Each pharmacy has a slightly different list so if you don't see your medication on one list check another. If your medication isn't on the list but a similar one is ask your doctor if it makes sense to switch medications.

Costco Drug List - Costco also has the lowest prices by far on some over the counter drugs like generic versions of popular allergy medications Allegra and Claritin. They also have great deals on Acid Reflux medications like Prilosec.

Local pharmacies like CVS and Rite Aid have similar plans although some of them require a small annual membership fee and have slightly higher prices.

These first three tools can result in significant savings. As an example, lets look at what happened with the woman I mentioned in the opening paragraph. We sat down and looked at the medicine bottles she had and I asked her if she would be willing to switch consider generic medications or switch to some similar medications if it would help her save some money. She happily agreed. As it turned out most of her medicines were brand name medicines for which generic equivalents were available. Two medications were not available as generics but there were alternatives that we could use which were just as good and they were available as a generic. In addition she was getting all of her medications through the local pharmacy at regular retail prices. By switching all of her medicines to generics or to similar medicines that had generic equivalents and transfering her prescriptions to a pharmacy with a generic drug plan we managed to get a 90 day supply of all 6 of her medicines for a grand total of $60. That was just $20 a month compared to the $600 monthly drug bill she had before. Her annual medication bill had been over $7,200. Now it was $240. Even better was the fact that her chronic medical conditions eventually were under better control because she didn't have to skip her medications.

These aren't the only tools you can use to lower drug costs. A few more are ilsted below.

Splitting Pills

Its an odd quirk of drug pricing that doubling the dose does not double the price. In fact in many cases a 100mg pill of a drug costs exactly the same as a 50mg pill. This is often true whether we are talking about the generic or the brand form of a drug. The cost for 30 pills of brand name Lipitor cholesterol medication at an one drug store at the time of this posting is $256 for the 20 mg pills. The same store charges the exact same price for the 40 mg pills. Buying the 40mg pill and cutting it in half would save a cash paying customer $1,536/year. Even if the patient has insurance and only pays a $30 copay they could save $180/year which isn't peanuts.

The generic version of the same drug is $15 for the 20mg pill, while the 40mg pill is only slighlty more expensive at $17. Buying the higher dose here woud bring the annual bill from $180 to $102. Not a lot but still $72 is enough to take a big bite out of the check at a nice restaurant. Better in your pocket than the pharmaceutical company.

While it is certainly a huge cost savings to split an expensive branded drug it will almost always save you money if you split pills. Most pharmacies sell pill cutters for just a couple dollars that make the job a snap.

One caution, capsules and time release medications can not be split. Check with the pharmacist to see if the drugs you are taking can but cut without changing their effectiveness.

OTC (Over The Counter) medications

Most people assume that getting medications through their drug plan is going to save them money but as I already mentioned above that is not always true. Sometimes co-pays can be more expensive than just paying for a drug out of pocket. This is also true of drugs that are available both with and without a prescription.

Common examples are antireflux drugs like Prilosec and Prevacid. These drugs are available in brand and generic form without prescription. It often pays to look at the non-prescription form on the shelves and compare it to the prescription price before purchasing. Sometimes the savings can be significant and it never hurts to ask if there is a similar drug that does not require prescription. The added benefit of nonprescription drugs is that it does not require an office visit or a phone call to get a new supply of these medications, and if you forget your medicine when you travel you can easily pick up a new bottle at the local pharmacy. Always check with your doctor first though to see if the OTC version is acceptable for your condition.

Many allergy medications that used to require a prescription are also available over the counter now and can often be significantly cheaper if purchased OTC.

Note: I recently checked the price of Nexium ( a popular drug similar to Prevacid and Prilosec for refluc and acid conditions). The price for the precription drug was $500 for 60 pills. The price for the exact same medication OTC ( brand not generic) was about $50 ! It pays to check.

Canadian Pharmacies

The question of purchasing through a Canadian pharmacy does not seem to come up as often today as it did 5 or 10 years ago. Perhaps because ther are other options now. Still I do get occasional questions from patients about this option. There are concerns with this approach.

First it is illegal to import drugs from Canada. Doing so violates federal law and any company that is doing this is knowingly breaking the law. This alone has to make a consumer question the company's ethics and if they are willing to break the law in one circumstance they may be willing to do it in ways that may not benefit the consumer.

These pharmacies are not under the juristiction of any U.S governmental agency and therefor are not liable if there is a problem wth the product they sell to you. There have been incidents of counterfeit drugs being sold through Canadian pharmacies to American citizens. Since they have chosen to break the law by exporting drugs illegally it should not be surprising that some of these companies would have less than perfect ethics about what they are selling.

Since there are other alternatives I would avoid purchasing drugs from Canadian pharmacies.

EPIC

The Elderly Pharmaceutical Insurance Coverage (EPIC) is a New York State program that is designed to help older New Yorkers afford their medications. There are several plans based on income which can pay part or all of the out of pocket expenses involved in the Medicare Part D drug coverage plan. There is a link down below if you would like more information about this program.

]]>http://MDAskMe.com/blog/2014/08/07/cheap-drugs-how-to-stay-healthy-without-putting-your-bank-account-on-life-support#comments0Vitamin D testing - The USPSTF questions the use of routine Vitamin D testingMichael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2014/06/24/vitamin-d-testing-the-uspstf-questions-the-use-of-routine-vitamin-d-testing
Tue, 24 Jun 2014 10:38:00 +0000http://MDAskMe.com/blog/2014/06/24/vitamin-d-testing-the-uspstf-questions-the-use-of-routine-vitamin-d-testingThe United States Preventive Services Task Force (USPSTF) has released its draft recommendation stating that there is insufficient evidence to support the use of routine vitamin D screening. The USPSTF is an expert group of scientists and physicians and they reached this conclusion after reviewing all of the current literature and studies done on vitamin D.

A number of studies in recent years have linked low vitamin D intake or low blood levels to a multitude of disorders. For this reason many media reports and shows like Dr. Oz have suggested that people get their vitamin D levels checked. Requests for vitamin D levels by patients have resulted in a large increase in the number of Vitamin D tests being done over the past few years but there have been no studies evaluating the benefits of such testing.

Despite the great interest in Vitamin D testing there have in fact been few studies which have demonstrated that low levels are the actual cause of any of the problems it has been linked to. This is important. Just because low levels are associated with certain illnesses does not mean they are the cause. We may have the relationship backwards. It is possible that low levels of vitamin D may not be causing the illness but instead the illness may be causing the low vitamin D levels. Or it maybe the low vitamin D is just a marker for poor health habits and its those habits that are causing illness not the low vitamin D.

Even if low vitamin D levels are the cause of some of these illnesses that does not necessarily mean that we can correct or prevent the illness by correcting the vitamin D level. Unfortunately there are few controlled trials demonstrating that supplementing low levels are either beneficial or safe.

One of the most important concerns with vitamin D levels is how we define "low vitamin D". Some studies and my own experience has shown that more than 80% of healthy patients are found to have vitamin D levels that would be defined as low by the current definition. For a level of anything to be considered abnormal it should either be "unusual" compared to the average individual or we should have evidence that when the vitamin falls below or above a certain level it can cause some form of illness or disease (high levels of vitamins can cause illness just as low levels can).

If the average person is 5 foot 6 we would not define 5 foot 7 as being short, but this is what's happening with vitamin D levels. The average healthy person in my own office seems has a vitamin D level of about 19 but anything below 20 is defined as low.

The second criteria for defining a measurement as being abnormal is that such levels have to be shown to cause disease. It is possible that even a level that is average could still be too low for good health. As discussed above though, few studies have really shown a causal relationship between low vitamin D levels and most of diseases for which links have been suggested.

There are also concerns about whether current vitamin D testing actually tell us what the true vitamin D levels are in our bodies. Vitamin D is a fat soluble vitamin. It is mostly stored in our liver and fatty tissues with a small amount circulating in the blood. When we measure the level in the blood we are making certain assumptions that may not be accurate. It is possible to have low blood levels of vitamin D and yet have plenty of vitamin D stored in our tissues and visa versa.

The USPSTF has determined that there are no proven benefits associated with routine vitamin D measurements but there are also concerns about the possible costs associated with routine testing. Not only are there costs associated with the test itself and with possible unnecessary treatments but there is also the possibility that treating levels currently defined as being low could actually be harmful. Many people think of vitamins as essentially harmless but vitamins are medications and it is well established that vitamin supplementation can under some circumstances cause disease and even increase the risk of cancer. Although currently there is no evidence linking vitamin D to an increased cancer risk, such studies can take decades to complete.

What the USPSTF recommendation is saying is that we may some day have evidence to support the use of vitamin D measurements and treatment but much more research needs to be done to answer this question. Without such evidence caution is advised because we don’t know if the benefits outweigh the real risks of doing these tests and possibly using treatments that could potentially be harmful.

]]>http://MDAskMe.com/blog/2014/06/24/vitamin-d-testing-the-uspstf-questions-the-use-of-routine-vitamin-d-testing#comments0EyeWire -Now you can help scientists discover how the eye sees the world and have fun doing it.Mmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2014/05/28/eyewire-now-you-can-help-scientists-discover-how-the-eye-sees-the-world-and-have-fun-doing-it
Wed, 28 May 2014 16:37:00 +0000http://MDAskMe.com/blog/2014/05/28/eyewire-now-you-can-help-scientists-discover-how-the-eye-sees-the-world-and-have-fun-doing-itThe brain is the most complex structure known to man. There are almost 100 billion nerve cells in the brain, each with up to a thousand connections to other nerve cells. That means there are over a trillion connections in the human brain.

The holy grail of brain research is to map something called the “Connectome” ( see The Human Connectome Project). The connectome is the complete map of all the connections in the brain. Mapping the connectome would give us an understanding of the brain that would allow us to find the causes of many neurologic and psychiatric disorders just like the human genome project and mapping of the chromosomes is providing scientists with the tools to uncover the genetic causes behind many diseases.

While the ultimate goal is to map the human brain connectome, we need to start with something a little less complex. Mapping the nerve connections in the retina will be an important first step in understanding the more complex connections of the brain itself and will also help us better understand diseases of the eye.

Until recently it was thought that the thin layer of nerve tissue at the back of the eye known as the retina had just one job, to sense light coming into the eye and send those signals on to the brain. It was thought that the brain did all the processing to turn the signals form the eye into the final image that we experience as sight. It is now known that the retina is not just a sensor but also does some of the image processing, sort of like a small additional brain. It processes some of the information before it is sent on to our big brain to make the final image. Scientists have discovered for example that the eye has circuitry which is capable of detecting motion before the signal is even sent to the brain. Understanding how the eye processes information and how all the connections in the retina work is an important first step to understanding the larger connectome of the brain itself.

Now everyone can make a contribution to this important area of science and have fun doing it by playing a game at Eyewire.org. The game designed by scientists at MIT is like a 3D puzzle. The game takes advantage of the human brain's strengths. Despite all the advances in computer technology, humans are still much better at detecting certain types of patterns and the game takes advantage of that skill. In a bit of an ironic twist, by working through the puzzle humans become the eyes of the computer so the computer can figure out how our eyes work.

Eyewire has been designed to be somewhat social as well. If you like, you can participate in competitions (this part is completely optional) and they even hold a weekly online happy hour during which you can chat with other participants although it is strictly BYOB and optional as well. So if you are interested in science, would like to contribute to an important project that may help expand our understanding of our own brain, help cure diseases and have fun while doing it check out Eyewire.

]]>http://MDAskMe.com/blog/2014/05/28/eyewire-now-you-can-help-scientists-discover-how-the-eye-sees-the-world-and-have-fun-doing-it#comments0Tick borne diseases - Don't let them take a bite out of your summer.Mmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2014/05/07/tick-borne-diseases-dont-let-them-take-a-bite-out-of-your-summer
Wed, 07 May 2014 21:45:00 +0000http://MDAskMe.com/blog/2014/05/07/tick-borne-diseases-dont-let-them-take-a-bite-out-of-your-summerThe summer is a time of increasing outdoor activities and with that comes an increased chance of exposure to insects and in particular ticks. While its possible to be bitten by ticks even in the depths of winter boths ticks and people are more active in the warmer months. This means the summer is a time when they are more likely to come into contact with each other so this is a good time to go over some of the illnesses that ticks carry. Its also an opportunity to dispell some of the myths and discuss a few precautions we can take to stay healthy when we are enjoying the outdoors.

Most people have heard of Lyme disease but how many have heard of Human Granulocytic Anaplasmosis or Babesiosis or even Rocky Mountain Spotted fever. Lyme disease has grabbed all the headlines in recent years but ticks can cause other illnesses besides Lyme and not all ticks carry the same diseases. Avoiding serious illness from tick borne diseases is a matter of preventing tick bites when possible, removing ticks as soon as possible, identifying the type of tick, being aware of the symptoms, and getting appropriate medical attention.

There a number of things one can do to avoid tick bites. Some of these things are easy and obvious. Others are more difficult and maybe impractical.

Ticks feed on animal blood. They bite all sorts of animals from tiny little mice to squirrels, deer, and humans. In order to catch their prey, ticks like to perch themselves on bushes or long blades of grass ready to cling on to any passing animal. For this reason one of the best ways to avoid ticks is to avoid areas with deep grass or brush. Trails with heavy brush along the sides are a common place for ticks to place themselves.

Some authorities recommend wearing long sleeve shirts and long pants with the cuffs of the pants tucked inside of boots. The idea here is that the more covered up we are the harder it will be for ticks to find exposed skin to bite into. This may be reasonable in cool weather but in the hot summer months tight fitting long sleeve shirts and pants with heavy boots will quickly lead to overheating and dehydration. Wearing such clothing will also make the wearer miserable and defeat the purpose of spending a day outdoors hiking or playing. Ticks are also very persistent and resourceful. A nymph deer tick is extremely small and given enough time they can find their way through even the heaviest clothing. Unless we are going to wear a space suit outdoors clothing is unlikely to defeat a determined tick.

Some experts have recommended wearing light colored clothing so that ticks will be easier to spot and remove but there have been some studies suggesting that certain types of ticks are actually attracted to lighter colors.

For all these reasons I don't usually recommend dressing to avoid ticks. After living on Long Island for my entire life and spending a lot of it hiking through wooded and grassy areas I have found that after spending the day outdoors, doing a good thorough body check at the end of the day has been a more practical approach that allows me to enjoy outdoor activities while at the same time avoiding tick bourne illnesses.

The best way to do a body check is to take a shower at the end of the day. Before going in the shower do a visual inspection in front of a full length mirror if possible. You obviously won't be able to see everywhere but thats OK for now. Once you finish looking everywhere that you can see go into the shower. Get the hands wet and soapy and then as you soap up the body feel for anything unusual. Soapy hands are very sensitive to small defects. You are feeling for something about the size of a sesame seed that is attached to the skin. Be sure to pay special attention to skin folds and areas with hair since these are locations that ticks seem to prefer but they can attach anywhere so start at the head and systematically work your way down examining every inch of the body right down to the feet. If done properly this shouldn't take much longer than a normal shower.

Most tick borne illnesses can be avoided if the tick is removed within 36 hours of attaching to the skin so make sure you do this at the end of any day when you spend a significant amount of time outdoors.

There are lots of myths and folk lore about how to remove ticks but the truth is that the best method is the simplest. Removing a tick is not much more complicated than removing a splinter. You want to get as much of the tick out as possible but beyond that there is nothing special about the method. You will need a pair of tweezers and if possible, a small container that you can seal the tick inside of. A glass jar or even a zip lock bag will do.

Once the tick is found the best approach is to grab the tick by the head as close to the skin as possible. Rock the tick gently back and forth while pulling until it breaks free and then seal it in a container. If there are small parts of the tick that remain behind leave them. Do not try to dig them out. Mouth parts from the tick do not carry disease so leaving them in will not increase the risk of contracting Lyme disease or any other illness. They will gradually fall out on their own over time. Trying to dig them out will only damage the surrounding skin and increase the risk of bacterial infection of the skin.

Once the tick is removed clean the area with an antiseptic, make an appointment to see your physician and bring the tick with you.

DO NOT use a lit match, peanut butter, vaseline, or any method other than the one described above to remove the tick. Those methods do not work, they can be dangerous, and they delay tick removal which increases the risk of disease transmission.

There are several types of ticks found in North America. In the Northeast the most common types of ticks seen are the Deer Tick, the Brown Dog Tick, the American Dog Tick, and the Lone Star Tick. Each type of tick carries different illnesses so it can be helpful to identify the type of tick one was bitten by in order to know which diseases we need to be alert for.

Lyme Disease
Lyme disease is probably the most common tick bourne disease that the public is aware of. Unfortunately a lot of the information found in the lay media is sensationalized or incorrect.

Symptoms:
Contrary to popular belief Lyme disease is not a universally disabling disease. Some people who contract lyme disease recover on their own without ever knowing they had an illness. Others are only mildly ill. In nearly all cases a 2-3 week course of oral antibiotics will completely eradicate the illness

Some of the the typical symptoms of early Lyme disease are a rash known as erythema migrans, joint pains, fatigue, chills, headache, and sometimes a fever. The rash is the classic bulls eye rash that usually occurs around the site of the tick bite and may expand and spread over time. While this is the classic presentation more than 30% of patients who get Lyme disease do not get the rash. When diagnosed at this stage oral antibiotics are usually given for 2-3 weeks with complete recovery.

Late stage lyme disease can cause damage to the nervous system, heart, and joints but even these cases usually respond very readily to antibiotics.

Post Lyme Disease syndrome or Chronic Lyme disease as it is sometimes called is a subject of some controversy. There are people who appear to have chronic symptoms and positive Lyme tests but there is little evidence that the symptoms they are experiencing is due to a chronic Lyme disease infection. the confusion arises from the fact that the Lyme disease test is not in fact a test for Lyme disease. What the test is checking for are antibodies to a protein on the lyme disease bacteria. We do not have a test for the bacteria itself. This is a problem because other conditions besides Lyme disease can cause the test to be falsely positive. In addition, if the person had a Lyme disease infection when they were younger and which they were treated for or unaware of, the anitbodies may remain positive many years after they recover from the infection. As a result, a positive Lyme test does not mean the person has an active Lyme Disease infection. The media frequently reports on patients who have difficult and long courses of Lyme disease requiring years of antibiotics but there is little or no evidence that these people actually have a persistent infection with the Lyme disease organism and even less evidence that long courses of antibiotics help with these conditions.

Human Granulocytic Anaplasmosis (HGA)
HGA can cause symptoms such as fever, chills, headache, muscle aches, and fatigue. The symptoms can vary significantly from one patient to another and the similarity of HGA symptoms to other illnesses like influenza can make diagnosis difficult. HGA should be considered in anyone who develops these symptoms within a week or two after being bitten by a deer tick.

Diagnostic testing is not always reliable and often will not be positive untl 7-10 days after infection. Since treatment needs to be started early to be most effective, diagnosis often rests on clinical symptoms and suspicion.

HGA usually responds rapidly to oral antibiotics but it can be a serious illness resulting in death in less than 1% of patients who contract it.

Babesiosis
Babesiosis can also cause flu like symptoms such as fever, chills, sweats, headache, body aches, loss of appetite, and fatigue just like HGA which again makes diagnosis difficult at times. It can be a serious life threatening illness in some individuals especially those with immune system defects, chronic illnesses, or those who have had their splens removed.

Diagnosis requires examination of a blood sample under a microscope or newer tests that can detect Babesiosis DNA.

Treatment requires the use of special antibiotics but requires confirmation of the diagnosis with lab tests

Rocky Mountain Spotted Fever (RMSF)Like the other tick borne illnesses patients with RMSF also have many of the flu like symptoms including fever, chills, headache, and muscle aches but they may also get nausea, vomiting or abdominal pain. The one symptom that sets RMSF apart is a rash. About 90% of patients with RMSF will have a spotted rash but sometimes it does not develop until late in the illness when treatment should have already begun.

RMSF is a serious illness and can be fatal. For treatment to be most effective it must be begun within 5 days of first symptoms but diagnostic tests are often not revealing until 7-10 days into the illness. For this reason as with HGA physicians must rely on symptoms and clinical suspicion when treating patients with RMSF

Erhlichiosis
Erhlichiosis is also accompanied by fever, chills, headache, malaise, and muscle pain but can also be accompanied by abdominal pain and confusion in some patients. A rash may be present but is only seen in about 30% of adults.

As with some of the other tick borne illnesses mentioned above treatment works best if started early but tests often don't turn positive for 7-10 days meaning that physicians must start treatment based on the history, symptoms, and physical exam alone using diagnostic testing only to confirm the diagnosis later on.

]]>http://MDAskMe.com/blog/2014/05/07/tick-borne-diseases-dont-let-them-take-a-bite-out-of-your-summer#comments0Why do perfectly heathy people pass out sometimes?Michael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2014/03/12/why-do-perfectly-heathy-people-pass-out-sometimes
Wed, 12 Mar 2014 15:11:00 +0000http://MDAskMe.com/blog/2014/03/12/why-do-perfectly-heathy-people-pass-out-sometimesHow many of us have been in this situation? Its a beautiful June day and you're sitting in church while a happy couple is taking their vows. The groomsmen are lined up on one side and the bridesmaids on the other when one of the bridesmaids begins to wobble. Only seconds later her knees buckle and in an eyeblink she slumps to the floor. Across town a police officer is in his doctors office for a physical. The nurse comes in to the room. She preps his arm to draw some blood, inserts the needle, and "THUNK". She looks up to see him slumped against the wall his glazed eyes staring at the ceiling. Later that afternoon a carpenter is framing a house. He swings the hammer but hits his thumb instead of the nail he was aiming for. Its not the first time he's done this but today is different. Nerve cells carry the pain signal up to his brain as usual but this time an overwhelming sense of nausea sweeps over him, he breaks out in a cold sweat, his eyes go black, and down he goes.

Most of us have witnessed one of these situations either in real life or in the movies. They elicit laughs in the movies and gasps in real life. Those nearby run to help. They often try to prop the person up. They may also fan them and give them something to drink in and effort to revive them. Usually in the movies someone throws a pitcher of cold water on the persons face and they magically wake up spitting and gasping to audience laughter.

So what are these events? Why does someone pass out at a beautiful event like a wedding? Why does a cop who has seen far worse pass out when he sees a small needle in his arm? Why does a carpenter who has sustained more than his share of injuries in his career suddenly hit the ground just because he hit his thumb? What causes these things to happen and more importantly, are they dangerous?

The medical term for someone passing out is syncope. Although many things can cause syncope, the events I am describing above are a specific but very common situation called a vasovagal event or vasovagal syncope. In each case a part of the nervous system known as the parasympathetic nervous system has been activated. When that happens the heart rate slows down and the blood vessels dilate leading to a drop in blood pressure. If conditions are right these changes make it more difficult for the heart to pump blood to the highest point in our body. Since that is where the brain usually is, the brain doesn't receive enough blood and oxygen so it begins to shut down. This can lead to symptoms like nausea, lightheadedness, cold sweats, and disturbed vision. If the problem is not recognized and addressed quickly the decreased blood flow eventually causes complete loss of consciousness and the person passes out.

There are many things that can trigger a vasovagal event. Pain, Emotional upset, dehydration, warm stuffy rooms, and for some reason getting up to urinate in the middle of the night seems to be a trigger for some people. The odd thing is that many times the trigger is something that has happened before without causing loss of consciousness. Why do the triggers sometimes cause a person to pass out and other times have no effect at all? It may be that there needs to be a combination of factors which predispose the patient to the event for the trigger to set it off. Perhaps the person is a little dehydrated. Maybe they have a viral infection. Perhaps they skipped breakfast or didn't get enough sleep the night before. It may be any one of these things or a combination of them. There may be factors we aren't even aware of that put the body in a condition where the trigger is just the final straw that causes the lights to go out.

Its not really clear why the nervous system reacts in such a way as to cause our heart to slow and our blood pressure to drop or what advantage it might provide, but fortunately the problem usually fixes itself. When the person loses consciousness they tend to slump or fall to the ground which means the head is lower down, blood flow is restored and consciousness returns. In most cases the person usually wakes up quickly. Loss of consciousness often lasts only a minute or two and frequently less. Unlike a stroke where there is a permanent complete loss of blood flow resulting in damage to brain tissue, vasovagal events only involve a very brief partial reduction in blood flow so there is generally no injury to the brain. For this reason vasovagal events are not considered to be dangerous as long as the person doesn't strike something after they pass out or fall from a high place when they lose consciousness.

The key to avoiding injury is recognizing the warning signs and taking steps to interrupt the event before loss of consciousness occurs. Most vasovagal events will be preceeded by some of the symptoms described above, nausea, cold sweats, darkening vision, dizziness, blurry vision, or spots in the vision. Some people describe a pounding in their ears prior to an event. The first event is usually difficult to prevent because the person has never had one before and they are caught entirely by surprise. Before they know what hit them they are on the floor. The second event is usually much different because the moment the warning signs appear a lightbulb goes on that says "Hey this has happened before". Once that happens it becomes a race against time. If the person takes action in the next couple of seconds they can stop the event in its tracks but they have to know what to do.

So what do you do when you feel like you are about to go down or if you see someone else who is on the way down or already on the floor? Remember this is a blood flow problem. We need to increase blood flow to the upper body to reverse the effects of a vasovagal event. There are several ways we can do that.

What to do:

Lay down on the floor. Sometimes people are too embarassed to lay down on the sidewalk or in public but you only have seconds. The time it takes to find a private place is often the difference between passing out and not. If you are afraid or embarassed to lay down you should consider what's more embarassing, laying on the floor voluntarily or crashing into it face first, because one or the other will definitely happen.

Once on the floor raise the legs to increase blood flow to the upper body

If there isn't enough room to lay down, bend over and put your head between your legs to get it as low as possible.

Heat causes blood vessles to dilate and blood to pool in the extremities. Cold does just the opposite. Applying cold compresses to the body will constrict blood vessels in the arms and legs and push more blood towards the head. Opening a door or window to let cool breeze in can also help.

Drinking cold liquids will also cause blood vessel constriction and help shift more blood flow to the head. Fluids will have the added benefit of treating dehydration if this is a contributing factor.

What not to do:

Do not try to find a private place to lay down. You wont make it.

Do not try to hold a person up when they are passing out. You will only prolong the time it takes to restore adequate blood flow to the brain and you will delay the recovery of consciousness.

Do not pour cold water on the persons face. They will wake up quickly enough on their own. Pouring liquid on the face of someone who is unconscious runs the risk of having them inhale water into their lungs turning a minor self resolving issue into a potentially dangerous one.

Loss of consciousness is a scary thing and while vasovagal events are generally not dangerous there are other things that can cause someone to pass out which can be more serious. Strokes, seizures, cardiac arrest, and irregular heart rhythms can also lead to loss of conscousness and obviously require a more urgent approach.

If you witness someone who has passed out check their pulse and their breathing. If they have no pulse or they are not breathing begin CPR and call EMS. If they have a pulse and are breathing on their own make sure their airway is clear, raise their legs, and give them a minute or two to wake up. If possible put a cold compress on their limbs and neck. If after a few minutes they do not wake up call an ambulance. If they do wake up resist the urge to help them to their feet right away. Give them a few minutes to recover. When they feel a little better help them to a sitting position. Once they are sitting,If available, give them something cold to drink. Wait 5 or 10 minutes at least and if they are feeling up to it help them to a standing position.

Any time someone loses consciosuness it should be reported to their physician. On rare occasions seizures and irregular heart rhythms can masquerade as something minor. Even if it seems like you have had a simple vasovagal event report it to your doctor so he or she can check you to rule out the possiblity of a more serious problem.

]]>http://MDAskMe.com/blog/2014/03/12/why-do-perfectly-heathy-people-pass-out-sometimes#comments1Red Yeast Rice Extract - Its not magic, Its a drugMichael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2014/03/08/red-yeast-rice-extract-its-not-magic-its-a-drug
Sat, 08 Mar 2014 10:21:00 +0000http://MDAskMe.com/blog/2014/03/08/red-yeast-rice-extract-its-not-magic-its-a-drugRed Yeast Rice Extract is a Chinese medicine which has been promoted as a "natural" treatement for high cholesterol. Proponents of this treatment ( usually not legitimate medical profesisonals) claim that it offers patients a way to lower their cholesterol without the side effects of medication.

As with many alternative therapies the assumption is that somehow we can magically have all the benefits of a conventional drug without any side effects. Unfortunately as I have stated before in my posts, there is no magic class of substances that can provide benefits with no risk of side effects. Natural is a meaningless and misleading word ( See Natural - What does that word mean?). Anything that you put in your body with the expectation of some beneficial effect is by definition a drug, and anything that has the possbility of producing beneficial changes in your biology is also likely to have an occasional unintended or unanticipated effect. We call these unwanted effects side effects.

Just because a particular treatment is made from something that comes from a plant doesn't mean it is any safer than a conventional treatment that is manufactured under strict quality control standards in a lab. So it comes as no surprise that Red Yeast Rice Extract contains no magic powers to lower cholesterol without side effects. In fact most users are completely unaware that this product works only because it contains one of the same statin drugs that we use to lower cholesterol. Statins are the drugs most frequently used by physicians to treat high cholesterol. They go by names such as Atorvastatin (Lipitor), Simvastatin (Zocor), Pravastatin ( Pravachol), Rosuvastatin (Crestor), and Lovastatin ( Mevacor). Lovastatin is the magic ingredient that allows Red Yeast Rice Extract to lower cholesterol levels, but you wont find that on the label anywhere. Its not magic, its a drug.

For those who are using Red Yeast Rice Extract because they want a more "natural" way to treat their cholesterol, there is nothing about this product that is any more natural than standard treatments. Many people who decide to use Red Yeast Rice Extract do so in the belief that its safer but nothing could be further from the truth. Unlike standard drug treatments which have to meet strict quality control standards and are regulated by the FDA, products which fall into the supplement category are not regulated by any agency. This means that these products do not have to state their actual ingredients and they don't have to post the dose of any active ingredients assuming there are any. The actual dose if they do post it may be much less than claimed, much more than claimed, or there may be none at all. Even worse, these products can be adulterated with any number of other ingredients that may have unwanted effects and the user would never know because no one is checking.

We need to remember that statin drugs require a prescription for a reason. These are powerful drugs and while they are largely safe and very effective there is still a small chance of side effects. For this reason patients on these drugs need to be monitored. An occasional side effect is muscle pains, but less commonly, a small percentage of patients may develop liver inflammation. Doctors screen for this before starting a stain medication and monitor for evidence of liver enzyme elevation with routine blood work periodically when patients are on cholesterol medications. If a problem is detected the medication is stopped and the problem resolves. If however a patient is not properly screened for liver disease before the medication is started or they are not monitored on the medication and a problem is not recognized, severe liver damage can rarely occur. Patients taking Red Yeast Rice Extract are not only getting an unknown dose of a powerful drug with unknown possible contaminants but they are not being monitored. For patients who really care about safety this is the worst of all possible choices to make.

For some patients cost may be the main concern. Some statin drugs, especially branded ones like Crestor can cost as much as $200 a month, but cost does not have to be an issue. Lovastatin, the very statin found in Red Yeast Rice Extract can be purchased at stores like Walmart and Target for pennies a day. A 90 day supply can be purchased without any insurance for as little as $10 which works out to about $40 a year. Lovastatin can significantly lower cholesterol and reduce the risk of heart disease when used properly and monitored but it makes no sense to take a product like Red Yeast Rice Extract when the real Lovastatin is available so inexpensively.

The bottom line is that Red Yeast Rice extract is NOT safer than other statins. It has the same potential side effects as any other statin but has the potential for unknown and widely fluctuating doses from one bottle to the next. Its purity can not be assured. It may be adulterated with other unknown substances. Taking it without proper medical supervision is potentially dangerous, and it doesn't save its users any money.

The only magic in Red Yeast Rice Exctract is the way its manufacturers lighten the wallets of its users while pretending to be the safer natural way to treat their cholesterol.

With recent cases in the news such as Terry Schiavo and more recently Marlise Munoz, it is painfully apparent that life is unpredictable and even the very young are sometimes faced with these difficult decisions. What is obvious from both cases is that when we don't prepare for these decisions our loved ones may be forced to battle the state and complete strangers for the right to make decisions about end of life care. It doesn't have to be that way though.

No legal document can completely protect us from the attempts of others to intrude upon these very personal decisions but having our wishes documented in black and white will usually make it much easier for our family and doctors to ensure that our wishes are respected. Fortunately it doesn't take much time or any money to prepare the documents you will need.

There are two important documents that everyone should have so that they are prepared for the unexpected. They are the Living Will and the Health Care Proxy. Both of these documents can be downloaded through the links below along with a set of instructions to help you fill them out. Both documents are important, but the Health Care Proxy which people are less familiar with is actually the more important of the two.

The Living Will is a document used to outline your prefernces should you be incapacitated and unable to make decisions about important health care issues such as cardiopulmonary resuscitation (CPR), and life support measures like mechanical respirators, dialysis, feeding tubes and any other treatment about which you would like to make your wishes clear. You can also detail in what circumstances you might want things to be done or not done. For example you may want to be on a ventilator if you were suffering from a condition that was reversible but not if you had a terminal disease like end stage cancer.

The Health Care Proxy is a simpler document to complete but probably the more important of the two. As useful as the Living Will can be in these situations its usefulness is limited by the great variety of circumstances which surround end of life. We can not possibly anticipate every situation. In addition, no matter how carefully we prepare our Living Will, it will be open to a certain amount of interpretation just like all legal documents. For this reason we need to designate someone to interpret our Living Will and to provide guidance for those situations which the Living WIll does not cover. This is what the Health Care Proxy does. It gives you the chance to legally assign someone to make these decisions for you in a situation where you are not able to make them for yourself.

Preparing these documents is only part of the process. Its just as important to discuss your wishes with your family and give copies of the documents to the person who is your designated Health Care Proxy and also to your doctor.

The documents provided here are vaild in NY State. If you live in another state you may want to check local regulations. Each state usually makes similar documents available through their own websites. While a lawyer may be able to help you anticipate situations you may not anticipate on your own it is by no means necessary to hire a lawyer to complete these documents. Even if you intend at some point to involve your lawyer you should fill out the documents listed here ahead of time. This can serve as a worksheet when you finally meet with a lawyer and they will also be fully enforceable legal documents should you need them before you get around to seeing a lawyer.

]]>http://MDAskMe.com/blog/2014/02/08/why-everyone-needs-to-have-end-of-life-documents#comments0Lung Cancer Screening - Is it time to get a CT scan?Michael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2013/12/31/lung-cancer-screening-is-it-time-to-get-a-ct-scan
Tue, 31 Dec 2013 13:03:00 +0000http://MDAskMe.com/blog/2013/12/31/lung-cancer-screening-is-it-time-to-get-a-ct-scanThe USPSTF has come out with a preliminary recommendation in support of low dose chest CT scans to screen for lung cancer in certain high risk individuals. This is an update of an earlier recommendation which concluded that there was insufficient evidence to recommend for or against such screening. More evidence has now come out allowing the USPSTF to update their recommendation. The new recommendation can be viewed here and is currently open for a period of public comment. If formalized and adopted after the public comment period is completed, CT scans will be given a Grade B recommendation. Under the Affordable Care Act (ACA also known as Obamacare) once a screening test receives a Grade B rating or higher all insurance companies will have to cover this procedure at no cost to their policyholders.

The recommendation does not cover all people who are or were smokers, only those who are considered high risk. For the purpose of this recommendation the definition of high risk includes all patients who meet the following criteria.

30 pack years or more of smoking- Pack years are calculated by multiplying the number of packs smoked per day times the number of years of smoking. For example, someone who smoked 1pack per day for 30 years or 2 packs per day for 15 years would have 30 pack years of smoking.

Age 55-79

Stopped smoking no more than 15 years ago

These criteria were developed after review of several studies and consideration of the benefits and harms of screening.

The benefits of screening obviously include the possibility of detecting lung cancer at an earlier more treatable stage. Although this would not prevent all lung cancer deaths, studies indicate significant reductions in mortality can be achieved with a properly designed screening program.

All screening test have potential risks for the patients who undergo them. In the case of Chest CT's the risks include false positives resulting in further scans, anxiety, and invasive biopsies, as well as radiation exposure. One study estimates that if all former smokers in the 50-75 age range were to receive annual chest CT scans it would result in a 1.8% increase in the number of lung cancers per year or about 640 extra cases of lung cancer. The earlier a person begins screening the greater the cumulative lifetime radiation exposure and the greater the risk.

Additionally, the CT scan may detect some harmless cancers. Despite common perceptions, some cancers can remain in the body for life and never cause harm. We do not have a good method for separating these cancers from the harmful ones so screening may result in the detection and treatment of harmless cancers and some patients will suffer side effects from these treatments.

Another potential drawback to lung cancer screening is that some proportion of screened patients who are current smokers will incorrectly assume that a negative scan means they are cancer free and use this as a license to continue smoking. A negative scan does not rule out the possibility that cancer is present. A small tumor may still contain millions of cancer cells yet be too small for the scan to detect. Smokers should be made aware that a negative scan has no diagnostic value at all and is NOT "a clean bill of health".

All of these factors were considered before making the current recommendation which was designed to best balance risk and benefit. The recommendation has not been finalized and will not be until the public comment period is over. It will be some time after that before most insurance companies will be required to include this benefit. If you feel you may be a candidate for lung cancer screening discuss this with your doctor.

It depends a lot on what an individuals particular risk is for the illnesses we are trying to prevent as well as their risk for developing the side effects that aspirin can cause. So what are the benefits of aspirin and what are the potential side effects? Aspirins is such a common drug that a whole mythology seems to have sprouted up about its life extending properties and for some it may be true but we need to look at science to separate the facts from the fairy tales.

The United States Preventive Services Task Force (USPSTF) is an independent government agency made up of experts in various fields of medicine. They periodically review all of the available scientific literature on a given subject and make recommendations based on the best available evidence. The last review was done in 2009 and they are currently working on an update to the recommendations which should be out sometime next year. Below is a summary of the existing recommendations.

The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Go to the Clinical Considerations section for discussion of benefits and harms.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.

The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years.

The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Go to the Clinical Considerations section for discussion of benefits and harms.

For people over 80 it seems that aspirin may not be a good idea because the risk of gastrointestinal bleeding becomes too high as we get older. For men under the age of 45 and women under 55 the risk of heart attack and stroke are too low to justify the use of aspirin. For people in between those age groups the decision is a little more complicated. In order to decide if you should take aspirin you need to calculate your cardiac risk and use the table below.

This table shows the risk level at which benefit ( heart attack and stroke prevention) exceeds harms ( gastrointestinal bleeding). To use the table, men should use the Coronary Heart Disease (CHD) calculator to determine their cardiac risk and women should use the Stroke Risk Calculator. To use these calculators you will need your blood pressure readings and cholesterol levels from your last exam.

Once you have your calculated risk you are ready to use the table. For example if a 62 year old man has a CHD risk of 10% then the benefits of aspirin outweigh the risks and he should consider taking a daily aspirin. The same could be said for a 58 year old woman who's stroke risk is 4%, while a 72 year old woman with a stroke risk of 10% probably should not take a daily aspirin.

A daily aspirin may keep the doctor away but it can also result in serious side effects that could land you in the hospital. Use this information only as a guide. Be sure to discuss the results with your physician before stopping or starting aspirin since medications you are taking may interact with your aspirin and other medical condition which you have may affect your risks of heart disease and bleeding.

]]>http://MDAskMe.com/blog/2013/12/12/will-an-aspirin-a-day-really-keep-the-heart-attack-away#comments0Preventing Heart Disease with almonds- Is this study Nuts?Mmelgar@doctormelgar.comMmelgar@doctormelgar.com
Nuts are known to be rich in a number of nutrients including unsaturated fats, fiber, vitamins and minerals. Some previous [...]]]>http://MDAskMe.com/blog/2013/11/26/preventing-heart-disease-with-almonds-is-this-study-nuts
Tue, 26 Nov 2013 00:00:00 +0000http://MDAskMe.com/blog/2013/11/26/preventing-heart-disease-with-almonds-is-this-study-nutsA study published today in the prestigious New England Journal of Medicine draws a connection between the daily consumption of tree nuts ( not just almonds) and a reduction in overall deaths from all causes.

Nuts are known to be rich in a number of nutrients including unsaturated fats, fiber, vitamins and minerals. Some previous observational studies seemed to show a correlation between nut consumption and reduced cardiovascular disease.3 Previously a randomized control trial showed that patients at high risk for cardiovascular disease who were put on a Mediterranean diet which happens to also include nuts had a significantly lower risk of cardiac events.4 Other studies have shown a connection between nut consumption and a reduction in inflammation, blood sugar and blood pressure as well as some types of cancer.

So are nuts the new miracle cure? Well yes and no. As with most nutrients its a matter of balance. The study published in the NEJM was an observational study. They followed a group of doctors and nurses over many years and documented their diet and recorded their illnesses. What they found is that there was an inverse relationship between nut consumption and death from all causes including heart disease, cancer, and respiratory diseases. Those who ate a serving of nuts once a day had the lowest risk.

As mentioned above, other studies in the past have also suggested that nuts may play a role in reducing many different diseases and nuts are now a recommended part of a balanced diet to reduce heart disease.

So where is the "No' part of the yes and no. There are two things we should bear in mind with these results. First, this was an observational study. It was not randomized and therefor there may be other factors not accounted for that resulted in fewer deaths. Its possible that people who eat nuts are more likely to participate in other behaviors that are healthy or maybe they avoid certain unhealthy behaviors or perhaps as a result of eating more nuts they are eating fewer potato chips and its the reduction in potato chip consumption that is really responsible for the reduction in deaths. This is a weakness of all observational studies and it must be kept in mind when we interpret the results.

Second, adding nuts to a poor diet may not improve anything if all we are doing is adding more calories and fat. The people in these studies were most likely eating nuts instead of something else. It would be naive to assume we could continue eating cake and ice cream and expect the nuts to counteract the effects of foods high in saturated fats. If nuts are to become part of a healthy diet the rest of the diet needs to be healthy as well. The nuts need to be consumed as a replacement for something else, not in addition to those things. Adding them to a bad diet may do nothing more than add to our waistlines.

While this study proves nothing it is suggestive and adds to a body of evidence that has been accumulating that nuts can be an important part of a healthy diet. If anyone really wants to improve their overall health and gain the health benefits that nuts may offer it would be best to overhaul their daily food intake to include nuts as part of a well balanced diet (See Choosemyplate.gov) or as part of the Mediterranean diet (See here)

]]>http://MDAskMe.com/blog/2013/11/26/preventing-heart-disease-with-almonds-is-this-study-nuts#comments0Antibiotics and Probiotics- Why you shouldn't take either without a good reasonMichael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2013/11/21/antibiotics-and-probiotics-why-you-shouldnt-take-either-without-a-good-reason
Thu, 21 Nov 2013 15:27:00 +0000http://MDAskMe.com/blog/2013/11/21/antibiotics-and-probiotics-why-you-shouldnt-take-either-without-a-good-reasonAs most people know, antibiotics are used to kill bacteria in our bodies. Recently products known as probiotics have become popular. For those who don't know what they are, probiotics are meant to promote the growth of bacteria in our body, primarily in our gut. In theory antibiotics are used to kill harmful bacteria and probiotics are meant to promote the growth of good bacteria but is anything ever that simple? We are starting to learn that the answer to that question is a resounding no.

One of the problems with this idea is that our understanding of bacteria has been a bit naive. The microscopic world of living things isn't really made up of good bacteria and bad bacteria any more than the human world is made up of good people and bad people. Some bacteria may be mostly good, others mostly bad, with the majority being somewhere in the middle, but every bacteria may have characteristics that may make it good or bad depending on the situation and the company it keeps just like people.

Its been known for a long time that an astounding 90% of the cells in and on our bodies don't belong to us at all. Most of what we consider "us" is really bacterial cells. Our own cells only make up a small percentage of the total. We call this collection of bacteria living in and on our body the Microbiome which is often shortened to the biome. A recent project called the Human Biome Project used new genetic tools to examine these major cohabitants of our bodies in a way that was never possible before. The results were surprising. What they found was that each of our bodies is inhabited by at least a 1,000 different species of bacteria and possibly many more. They also discovered that the type and amount of bacteria each person carries are so specific that a given person's microbiome might be as unique as a set of fingerprints.

Along with the publication of the Human Biome data there has been a lot of research into the effects that our microbiomes have on our health. There is preliminary evidence that certain combinations of bacteria may be associated with a greater or lower risk of diseases such as Diabetes, Obesity, Inflammatory Bowel Disease, and even Alzheimer's as well as many other conditions. They have also found that the biomes of people living in modern societies are less diverse than those of people living in more primitive conditions. This means that those of us in the industrialized world have fewer species of bacteria living with us than people living in the amazon jungle. While there are many theories about why this is so including exposure to antibiotics, no one knows for sure what has lead to the loss of bacterial diversity among people who live in modern societies. What that means for our health we don't know at this point. This research is all in its earliest stages. We have no idea what bacteria are important, how greater or lesser diversity affects health, whether we can make meaningful changes in the bacteria that live among us, or even if those changes would be helpful or harmful.

So what does this tell us about the use of antibiotics and probiotics? It means that for all of the reasons mentioned above we need to tread carefully when we take antibiotics that may reduce the number of bacterial species in our biome or take probiotics whose effects we really know very little about despite the varied and growing claims of marketers. Anyone who says they understand the microbiome and that they know how to change it to improve your health isn't telling the truth. We just aren't there yet and when you don't fully understand something its generally best to make as few changes as possible unless its done as part of a research study.

Antibiotics are one of the most important advances in modern medicine, but just as bacteria are not all good or all bad neither are antibiotics. These drugs are invaluable when we need to treat a dangerous bacterial infection. Over the decades since they were invented antibiotics have saved millions of lives. Initially these drugs were used primarily for serious life threatening infections but as the costs came down and they became widely available antibiotics became victims of their own success. Today many people think of antibiotics as a cure all for more minor illnesses and in many cases they are used for conditions where they are not effective at all.

Bronchitis, sore throats, ear infections, and sinus infections are some of the most common conditions for which antibiotics are prescribed today yet 90% of these conditions are caused by non-bacterial conditions like viruses and allergies which will not respond to antibiotics. Even worse, tens of thousands of people with colds are treated with antibiotics in the US alone every year and antibiotics are completely ineffective in treating these viral infections.

When we use antibiotics for conditions that don't require them two things can happen which are harmful to us. First, antibiotics are indiscriminate. They kill many different types of bacteria including many of the ones which may be performing important functions in the body. When these innocent bystanders are killed there can be short term side effects such as severe diarrhea, or yeast infections, but there may be other long term side effects we don't even know about yet like increased rates of diabetes, cancer, or heart disease. Secondly, bacteria develop resistance to antibiotics when they are exposed to them frequently. Every time you take antibiotics you kill off bacteria which are not resistant and leave behind resistant bacteria to reproduce and increase in number. Each round of antibiotics increases the percent of bacteria that contain resistance genes, and bacteria are voracious collectors and traders of resistance genes. When one bacteria develops resistance the gene can then be passed on to other bacteria. They can even be passed on to bacteria of other species. The use of antibiotics when they are not needed can therefor result in the emergence of a resistance gene which will linger in our microbiome and potentially be passed on to a dangerous organism that invades our body weeks or months later.

This doesn't mean we should never use antibiotics. They are crucial and important drugs when used correctly. The key is to use them correctly. Physicians often prescribe antibiotics because they are short on time and find it far more time consuming to explain to a patient why they don't need antibiotics than it is to just write a prescription, especially if the patient is going to leave angry when they don't get what they want.

When patients feel sick and go to the doctor they should remind the doctor that they have come for a diagnosis, not a specific treatment. Do not tell the doctor that you have been sick too long and want an antibiotic. Don't tell the doctor that you "can't afford to be sick". Nothing will bring out the prescription pad quicker than these sorts of comments. Tell the doctor you will take an antibiotic if you really need one, but you would prefer not to if they think the problem will clear up on its own with rest and time. Most physicians are relieved to know they are dealing with a patient who isn't going to pressure them for antibiotics and will be happy to discuss other options especially if the antibiotic is unlikely to help.

The bottom line is that all of this research is extremely interesting and promising but its early days. Selling products such as probiotics and prebiotics at this point is putting the marketing way ahead of the science. Many companies are selling capsules of probiotics and others are putting it in foods like yogurt. Unfortunately most of the claims being made are either exaggerated or have no science behind them at all.

The idea behind probiotics is to take so called "good" bacteria and consume them in such a way as to populate the bowel with them creating a healthier state. There are a number of flaws in this theory based on our current state of knowledge though.

1) We don't know which bacteria are "good" - Some bacteria may be good in certain places and not others or when present in combination with certain bacteria but not others. Remember too that we all have very unique microbiomes and it may turn out that a bacteria which is beneficial in one person may have no effect or even be harmful in someone else.

2) We don't know if we can effectively seed the body with new bacteria - It might seem logical that taking a pill filled with a particular bacteria would allow it to grow inside your bowel like seeding your front lawn but that may not work. The desirable bacteria may be absent because the conditions required for them to grow don't exist in the particular body we are trying to put them in. If you spread seed on a bare dry hard patch of your yard it may remain bare for the same reason it was that way in the first place, not enough water, too little sun or some other condition that wasn't conducive to growth. The same may be true when we try to seed an inhospitable bowel with new bacteria.

3) The microbiome is much more complicated then we thought - A defective microbiome may be missing a lot more than one or two species of bacteria. Trying to seed your bowel with "good" bacteria after they have been presumably wiped out may be like trying to repopulate the rain forest after its been stripped bare by seeding it with a few parrots and rubber trees. You may have a some trees and birds but you wont have a rain forest. Putting probiotics into our guts after our diets or medications have altered the normal collection of species may not return our bowels to a healthy state even if the bacteria are able to grow and fill in the void.

A great deal of research is going on in this field but we have only scratched the surface and there is a lot we still don't know. Until we know more it's probably best not to intentionally alter the normal bacteria that inhabit our bodies any more than necessary unless we have good evidence that the benefits will outweigh the possible harm.

Whenever possible limit antibiotic use to those situations that truly require them and for the shortest amount of time needed to clear the infection. All colds and most cases of bronchitis, sore throats, and sinus infection do not require antibiotics and will usually get better just as quickly with rest and over the counter medications that can relieve symptoms until the illness passes on its own.

Probiotics may have some role in treating diseases related to a disturbed microbiome in the future but current preparations have shown no benefit in many studies and mixed results in others. Most claims made by marketers of probiotics are exaggerated and not based on sound science. Attempts to alter the bacterial species in our bodies with probiotics should be done only under the direction of a physician in the limited situations where this has been proven to be helpful.

Last week saw the announcement of new cholesterol treatment guidelines published by the American Heart Association and the American Cardiology Association. Many believe that the new guidelines will result in millions of additional people being put on statin drugs like Lipitor, Zocor, Crestor, and the many generic equivalents. While this may be true the new guidelines also mean that some people who would previously have been put on statins won't need to.

The main difference between the new guidelines and the old ones is that the new ones put less of an emphasis on the numbers and a greater focus on risk factors that lead to cardiovascular diseases like heart attacks and stroke. Instead of treating everyone with a given cholesterol level the new guidelines recommend treating everyone in certain high risk groups regardless of their cholesterol level.

Its now recommended that everyone who is diabetic be put on statins even if they have normal cholesterol levels. in addition anyone who has a history of heart disease should be on cholesterol meds as well as anyone with a calculated cardiovascular risk of 7.5% or greater. These recommendations will result more people being treated but another recommendation, that patients without diabetes and with normal cardiac risk only be treated if their LDL (bad cholesterol) is more than 190 may mean that some patients currently on statins might be taken off.

There is a lot more to heart disease than cholesterol levels. More and more evidence points to inflammation as an important factor in causing damage to the walls of our arteries that leads to the formation of plaques and ultimately heart attacks and strokes. As it turns out, in addition to lowering cholesterol levels, statin drugs also have the ability to reduce arterial wall inflammation as well.

When someone has a heart attack or stroke it doesn't happen over night. For decades before the heart attack a slow process was taking place. It all begins with inflammation in the wall of the artery. Arterial wall inflammation can be caused by many things. High blood pressure, diabetes, smoking, and genetic factors can all lead to inflammation. Once inflammation develops it allows LDL cholesterol particles to seep beneath the surface of the artery wall and lodge there promoting a number of steps that ultimately lead to the formation of plaques. Inflammation also makes those plaques more likely to rupture and cause a heart attack ( see "How do heart attacks happen?")

It may turn out that the anti-inflamatory effects of statins are more important than the cholesterol lowering ability of these medications. This is why the current guidelines focus more on conditions that increase the risk of preexisting inflammation then they do on the cholesterol level itself.

If you are a diabetic, have had heart disease or are concerned that you are at risk for heart disease, discuss this with your doctor. If you know your recent cholesterol numbers and blood pressure you can use the calculator below to determine your cardiac risk. If the estimated risk is over 7.5% make your doctor aware and ask him about your options. Finally, if you have no risk factors or you think your risk of cardiac disease is low and you were started on a statin just because your cholesterol was a little high ask your doctor if you still need to take this drug. It may no longer be necessary.

]]>http://MDAskMe.com/blog/2013/11/18/new-cholesterol-guidelines-whats-changed-and-what-does-it-mean-for-you#comments0How do you save a life ? - Just swab your cheekMmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2013/11/10/how-do-you-save-a-life-just-swab-your-cheek
Sun, 10 Nov 2013 08:56:00 +0000http://MDAskMe.com/blog/2013/11/10/how-do-you-save-a-life-just-swab-your-cheekScores of people die yearly from diseases that could be treated and cured if only they had a matching bone marrow donor. These deaths occur in children, young adults, mothers, fathers, wives, and husbands. The saddest part is that many of them die even though there is a perfect match 2 states over, down the street, or even next door, but no one knew because they weren't registered.

Only about 30% of the people who need a bone marrow transplant will have an acceptable match in their family which makes the bone marrow registry critical for the majority of patients who need this life saving procedure. Unfortunately just 3% of Americans have registered with the national bone marrow registry and an ideal match can be a very rare thing. Although there are approximately 10 million possible donors in the registry about 1,000 people die every year because they don't have a match. That's 1,000 people every year who might be alive today if all eligible donors just took the time to swab their cheeks.

Joining the bone marrow registry is easier than ever. Not too long ago it required a trip to a lab or participation in a special bone marrow drive, but not today. Now you can register from the comfort of your own home. To register all you have to do is sign up with Be The Match through the web site listed below and they will send you a kit. Swab your cheek, send it back, and Be the Match will do the rest.

Less than 1 out of every 540 people who submit samples will ever be asked to be a donor. Of these about 30% will be asked to donate bone marrow and the rest will only be asked to donate blood from which stem cells can be extracted and transplanted. Submitting your sample to the registry does not obligate you to donate bone marrow or stem cells, but it gives you the option and it gives someone else a chance at life.

]]>http://MDAskMe.com/blog/2013/11/10/how-do-you-save-a-life-just-swab-your-cheek#comments0Omega 3's (Fish Oil and Flax Seed Oil) who should take them?Michael Melgar, MDMichael Melgar, MD
Omega 3's became [...]]]>http://MDAskMe.com/blog/2013/11/03/omega-3s-fish-oil-and-flax-seed-oil-who-should-take-them
Sun, 03 Nov 2013 20:02:00 +0000http://MDAskMe.com/blog/2013/11/03/omega-3s-fish-oil-and-flax-seed-oil-who-should-take-themIt seems like everyone is taking Omega 3 tablets these days doesn't it? Fish Oil capsules and Flax seed oil supplements containing Omega 3's are advertised and sold in every health food store and pharmacy. Common wisdom is that these supplements are good for everything from preventing heart disease to lubricating joints.

Omega 3's became popular when studies showed that people who ate more fish seemed to have lower rates of cardiovascular disease. Scientists knew that some types of fish were high in Omega 3 fatty acids. Because they have some anti-inflammatory effects it was thought that the Omega 3's might explain the link between higher fish intake and lower rates of cardiovascular disease. Omega 3 supplements were also found to lower triglycerides and since high triglycerides ( a type of bad cholesterol) are associated with an increased risk of heart disease this theory was attractive.

There were a few weak points in the theory though. First, the original studies were not randomized controlled trials. They were population studies. That means they looked at diet and diseases in one group of people like Eskimos or Swedes and compared them to another group of people like Americans or Australians. Its possible though that there may have been other lifestyle or genetic differences between the two groups aside from their fish consumption that could explain the difference in heart disease. Additionally, the people who ate a lot of fish may have had lower rates of heart disease not because they were eating more fish but because people who eat more fish tend to eat less red meat. Another weakness in the theory is that fish are not a bag of Omega 3 fatty acids. They are complex foods made of various proteins, carbohydrates, fats and many other minor components. Its possible that even if a link exists it may be something other than the Omega 3's in the fish that are causing this effect.

Over the past 3 decades many studies have been done to try and sort out the possible link between Omega 3 fatty acids and heart disease as well as other illnesses like arthritis, depression, and cancer. Because of all the issues described above, when randomized controlled trials are done the benefits seen in the original population studies are often not seen in the controlled trials and most of the hoped for benefits of Omega 3's have not been found when high quality studies were done to look at these issues.

Some of the proposed uses of Omega 3's are listed below

Prevention of Cardiovascular Events:

Despite the wide spread use of Omega 3's and even recommendations from physicians there is no good evidence that Omega 3 supplements can reduce the risk of heart attacks or strokes in people of average risk. Even among high risk patients and individuals who have had a prior stroke or heart attack the evidence of benefit from Omega 3's is weak.

Lowering Triglycerides:

Fish Oil does seem to lower triglyceride levels significantly but also raises LDL ( bad) and HDL (good) cholesterol levels. Unfortunately this does not seem to result in a corresponding reduction in heart disease.

Arthritis:

For conditions such as arthritis the evidence is similarly disappointing. The majority of patients who suffer with arthritis have a type known as osteoarthritis and its clear that in this group Omega 3's offer no benefit. Among a very small minority who have rheumatoid arthritis there may be some benefit but even this is marginal.

So whats the bottom line?

Although the benefits of Fish Oil capsules and other Omega 3 supplements appear to be in question, the benefits of eating fish are not. Two or more servings of fish per week is a recommended part of any healthy diet. What is clear from these studies though is that we can't try to cram part of a fish into a pill and expect to get the same results.

]]>http://MDAskMe.com/blog/2013/11/03/omega-3s-fish-oil-and-flax-seed-oil-who-should-take-them#comments0A cold? the flu? allergies? or a sinus infection? how do you know what you have?Mmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2013/10/23/a-cold-the-flu-allergies-or-a-sinus-infection-how-do-you-know-what-you-have
Wed, 23 Oct 2013 21:42:00 +0000http://MDAskMe.com/blog/2013/10/23/a-cold-the-flu-allergies-or-a-sinus-infection-how-do-you-know-what-you-haveAs you wake from a night of restless sleep the alarm clock is ringing and the loud clanging makes your head pound. You reach to shut it off and realize in addition to that nasty headache, you're tongue feels like cardboard. You open your mouth and move your tongue around trying to moisten your mouth but a night of mouth breathing has left it as dry as the Gobi. When you try to breath through your nose its completely blocked. It doesn't help that during the night someone has stuffed bricks in your sinuses. With a groan you drop back onto the bed and put a pillow over your head. Its going to be a long day.

This time of the year sniffling patients are lining up at their doctors offices looking for some kind of relief from the type of misery described above. Is it the flu, a nasty cold, severe allergy symptoms, or a sinus infection? All they know is they need some relief. All of these conditions can cause uncomfortable nasal congestion but the treatment for each can be very different so how do you know which one you have?

It would be great if the doctor could swab your throat, take some blood, or do a scan and tell exactly what was causing these symptoms but sadly no such test exists yet. In order to determine the source of our misery doctors have to rely on the oldest and still most important of medical tests. Its called the medical history. Ask the right questions and listen to the answers. There are clues in the details of your symptoms and if a doctor knows the right questions to ask he can usually figure out what's going on despite the lack of any useful diagnostic tests for these conditions. The history of your illness, what symptoms you have, when they started, whether they have gotten better or worse, how long they have lasted, what other symptoms accompanied your stuffy nose can all help us figure out why your day started off so badly..

So how do you tell what the problem is when you have a stuffy nose? Here are some clues.

1) A Cold also called an Upper Respiratory Infection or URI

URI's can be caused by any of 100 or more viruses. These illnesses can last from a few days to a few weeks. Sometimes patients will say " I know this isn't a cold because I always get over a cold in a couple of days" but cold viruses can vary greatly in their severity and duration. Some colds may only last a couple of days but others can last a couple of weeks.

In additional to nasal congestion patients suffering from colds may have other symptoms like scratchy throat, mild body aches, headaches, and sometimes a low grade fever. Usually the symptoms gradually worsen over the first 3 days, then plateau for several days, and finally improve over the next few days to two weeks.

2) Allergies

We may imagine allergies as a spring time problem but in fact allergies can occur any time of the year. In the spring tree pollen fills the air and can be seen as a dusty green layer on our cars. Grass pollen is a major summer nuisance. Ragweed pops up in the early fall and the wet leaves of late fall can be a breeding ground for molds. When winter finally brings its cold chill and we close our windows you would think all this allergy stuff would end but the warm and dry air in our homes creates ideal conditions for dust mite allergies. In short, there is no season when we are free from the possibility of allergies.

Allergies can cause symptoms that people often confuse for cold symptoms and its easy to see why. We're all familiar with the typical watery eyes and runny nose that everyone seems to be suffering from in the allergy commercials but few people realize that a persistent cough, sore throat, fatigue, and headache can also be common allergy symptoms. What gets confusing is that someone who is suffering from allergies can have one of these symptoms, some of them, or all of them. For example its possible to have just a cough and sore throat without a runny nose or sneezing. Sometimes patients just have fatigue and nothing else. The classic picture of sneezing and watery eyes does sometimes occur but the majority of people who have allergy attacks don't have that classic set of symptoms. Unlike colds though, allergies usually will not cause body aches and you won't get a fever ( temp of 101 or more).

In general if a patient has any of these symptoms and its been only a week or two it may be difficult to know whether they have an allergy or a cold unless they have a fever or body aches. Unfortunately for the prospects of making a diagnosis most people with colds don't have a fever either and many don't have body aches.

After a couple of weeks the picture usually becomes clearer. Most people suffering from a URI will be well on their way to recovery at that point but a person who reports several weeks of constant or waxing and waning symptoms without a fever and no sign of resolution is much more likely to be suffering from allergies. A history of seasonally recurring symptoms is also another clue that this could be allergies.

Finally, patients will often comment "I know this isn't allergies because I don't have allergies" with the mistaken belief that allergies are a childhood phenomena and if they didn't get them as a child they are out of the woods. In fact the opposite is true. Most adults who have allergies developed them at some time in their adult life despite an allergy free childhood. So don't assume that your runny nose has to be a cold just because you are 35 and have never had allergies before.

3) Sinus Infection

Often times a patient is diagnosed with a sinus infection when they have severe sinus congestion or sinus pain. Its a common belief that these symptom indicate a bacterial infection especially if the patient reports that they are producing green mucous as well, but studies have cast doubt on this idea.

Research has shown that most people with prolonged sinus congestion do not have a bacterial infection and the color of the mucous does not correlate with the presence of bacteria either. The majority of these situations appear to be caused by viral infections and allergies, while others may be due to a fungus infection. For this reason antibiotics are really not helpful in most of the cases where patients are diagnosed with a sinus infection. It can be confusing for patients because they are usually given antibiotics for these conditions and ultimately they do get better but the evidence is that they would have gotten better just as quickly without the antibiotics and with a lower risk of side effects.

There are some cases in which bacteria may be the culprit. Bacterial sinus infections sometimes arise when congestion has persisted for a while and bacteria has a chance to colonize the collection of mucous. Eventually these bacteria may invade the tissues lining the sinus cavity causing a sinus infection. In such cases a patient will usually report a period of persistent or waxing and waning sinus congestion for several weeks which is then punctuated by the development of a fever or a sudden worsening of pain around or behind the eyes.

No matter what their previous experience, patients should never insist that they have a sinus infection and demand antibiotics. Too often faced with this situation and not wanting to be confrontational a doctor will write a prescription for antibiotics. This will pacify the patient for another 10 days but which buys some time but exposes the patient to potential side effects and usually does nothing to shorten the course of the illness.

4) The Flu

This is probably the easiest of the above conditions to diagnose. Patients with the flu can certainly have nasal congestion, watery eyes, and a cough or sore throat just like a cold or allergies but the thing that distinguishes the flu from the other conditions are the body aches and fever. Patients suffering with the flu often have debilitating body aches. Its not uncommon for me to hear a flu sufferer say with a groan of exasperation "Doc everything hurts, even my hair hurts" as they struggle to lift their head just high enough off the exam table to look at me with their glassy eyes. They usually have a fever over 101 and sometimes more than 104 with chills and shakes that make the body aches even worse.

Unlike the other conditions there is a test that will confirm if a patient has the flu. If the doctor is unsure or they need confirmation they can do a culture. To do this the doctor inserts a soft swab deep into the nasal passage to collect a specimen. A quick test will sometimes be done in the office but this test can suffer from a high rate of false negatives. The specimen can be sent for a viral culture which takes several days but is more reliable.

1) URI and Flu

Symptomatic Relief:
There are many products advertised for treating colds but despite all the hype they all have some combination of the following common ingredients in them.

All cold and flu remedies have one or more of the following five ingredients:

Nasal Congestion: Pseudoephedrine or Phenylephrine

Fever, Headaches, Body aches: Acetaminophen or Ibuprofen

Expectorant: Guaifenesin

Cough Suppressant: Dextromethorphan

Sleep: Any of a number of antihistamines such as Doxylamine or Diphenhydramine

Other versions of these products will contain different combinations of ingredients but despite the fancy commercials and marketing hype none of them have any special magic. They all include various ingredients from the menu of 5 listed above.

In addition to the liquids and pills there are nasal decongestant sprays which may be useful sometimes. Sprays like Afrin contain oxymetazline that constricts the blood vessels in the nasal membranes shrinking those membranes and opening the nasal passages. They usually work very quickly in 5-10 minutes and can give dramatic relief of symptoms. The disadvantage of these sprays is that the body becomes tolerant to them quickly and if continued for too long the patient will experience a rebound effect when they stop the medication. The rebound effect is a swelling of the nasal tissues that causes congestion that can be as bad or worse than the original symptoms. For this reason these sprays should only be used intermittently and only for a few days at a time.

When buying a cold or flu remedy you should purchase one that only contains the ingredients you need.

Antiviral medications:

URI's are always caused by viruses. There are a number of different viruses that can cause a URI and currently there are no effective antiviral medications for any of these viruses. Treatment is therefor limited to symptom relief. Antibiotics will absolutely never help when you have a cold.

The Flu is caused by various strains of the influenza virus as opposed to colds which can be caused by many different viruses. There are several antiviral medications which are effective against the influenza viruses to some degree. These are not miracle drugs though. Anti-influenza drugs will shorten the course of the flu but only by about a day on average. They can also decrease the severity of the symptoms but in order to get any of these benefits the medications must be started within 48 hours of the first symptoms. These drugs can have side effects such the most common of which is nausea. Rapid resistance to these drugs has also been reported during flu outbreaks. For all of these reasons many experts do not recommend using anti-influenza medications in otherwise healthy individuals who develop the flu.

Others:

Vitamin C, ZInc, Echinacea as well as many other home remedies and herbal supplements have been used to treat colds. Some of these products may have benefits in limited circumstances. Searching for accurate and reliable information about these products is not easy. Most of the information on the internet is from companies that prmote these products or from fans of the products. There is almost a religious following of people devoted to home remedies and they all seem to have web sites so separating fact from fiction can be difficult. Fortunately the National Institute of Health has created a division devoted to researching alternative treatments through standard scientific methods and much of this information is available on line. For more information on any of these products visit the National Center for Complementary and Alternative Medicine (NCCAM).

2) Allergies

Anithistamines: Allergies are usually treated with antihistamines. Older antihistamines tended to be sedating. These include diphenhydramine (Benadryl) and brompheniramine (Dimetap) among many others. in the past two decades a number of non-sedating antihistamines have come to market. several are now available over the counter including loratadine (Claritin) and fexofenadine (Allegra)

Nasal Corticosteroid Spray: If antihistamines alone don't control the symptoms a nasal spray may be used which contains corticosteroids. Unlike antihistamines, these products require a prescription. They include fluticasone (Flonase), mometasone furoate (Nasonex), triamcinalone (Nasacort), and beclomethasone dipropionate (Vanceril) among others. These spray are unlike the sprays mentioned above. They contain steroids which reduce inflammation. They do not work as quickly as the decongestant sprays but they do not create dependance or rebound effects and can be used as long as needed. The will not work for colds and flu however.

Oral Steroids:When first line treatments like antihistamines and nasal sprays are not sufficient to control symptoms doctors will sometimes use a short course of steroids taken by mouth. The oral form of steroids have a much more potent effect than the nasal spray form but come with some risk of potential side effects so they are reserved for patients with severe symptoms that have failed other treatments.

3) Sinus infections

A sinus infection in many ways is similar to an abscess. An abscess is a pocket of fluid in which harmful bacteria are growing. Because there is this pocket of fluid the bodies natural defenses don't work as well. It is more difficult to get white blood cells to the source of the infection because there are no blood vessels running through this space. White cells do eventually make it to the source of infection but they are not as effective as we would like them to be. Eventually a mixture of bacteria and white cells accumulate and we call this puss. If the abscess is not opened and drained the collection may grow in size and the bacteria may eventually enter the blood stream causing a more serious infection. Antibiotics may be of only limited value since blood flow is needed to distribute them to the source of infection so the same problem that prevents white blood cells from being fully effective affects antibiotics as well. The only way to treat an abscess is to drain it and then use antibiotics to mop up the remaining infection.

A sinus cavity is a lot like an abscess. To begin with a sinus cavity is a large empty space. When we get a cold or allergies the space may fill with fluid. Normally this fluid drains on its own through a small opening that exists in each sinus cavity but if the tissues that line the sinus are inflamed enough the opening may become very small or may close all together. If this condition persists for long enough and the right type of bacteria are present an infection may develop.

Its important to understand though that congestion and sinus pressure themselves are not proof of a sinus infection. They are merely the conditions that may, if given enough time, lead to a sinus infection. Usually if congestion is treated properly and early enough the infection itself will never occur. Even when a true sinus infection does occur, just like with an abscess, antibiotics alone may not cure the problem. Getting the sinuses to drain is just as important as starting the correct antibiotic.

So lets say its 2 weeks after that fateful morning when you awoke feeling miserable with a brick in your sinuses. You have been muddling along using over the counter medications and home remedies but today when you woke up something was different. Now you have a fever and that pressure behind your eyes has turned into a throbbing pain. It wasn't like that when you went to bed last night or in any of the preceding 14 days since this all began. Deciding that you have been patient long enough you make an appointment to go to the doctor. Upon telling the doctor your tale he examines you and finds your temperature is 101. He agrees that you probably have developed a sinus infection and that there is a reasonable chance that it may be bacterial.

The Antibiotics of choice in these situations are drugs such as Amoxacillin, Augmentin, or Levaquin and there is a good chance you will be put on one of these for about 2 weeks.

Another approach to treating sinus infections is to treat the drainage issue in addition to the possible infection. To accomplish this we may add a decongestant or an oral steroid to the antibiotics. These medications can open up the sinus passages so the mucous drains. In a way its like draining an abscess and this will usually result in more rapid resolution of symptoms. This approach has the added benefit of treating any possible allergy condition that may have lead to the sinus congestion.

]]>http://MDAskMe.com/blog/2013/10/09/why-did-your-doctor-give-you-a-drug-that-causes-hot-dog-fingers-how-to-sort-out-medication-side-effects#comments0How do Heart Attacks Happen?Michael Melgar, MDMichael Melgar, MD
We've all heard stories of people who have had heart attacks. Maybe a family member had some chest pain and went to his doctor. He had been having chest pains off and on [...]]]>http://MDAskMe.com/blog/2013/09/17/how-do-heart-attacks-happen
Tue, 17 Sep 2013 10:17:00 +0000http://MDAskMe.com/blog/2013/09/17/how-do-heart-attacks-happenIn last weeks blog entry we discussed stress tests and who should have one so this week I thought it would be useful to go over what a heart attack is and how it occurs.

We've all heard stories of people who have had heart attacks. Maybe a family member had some chest pain and went to his doctor. He had been having chest pains off and on for a while but never told anyone until one day they got too painful to ignore. His doctor admitted him to the hospital and after a series of tests they told him he had a heart attack. A few days later he was released home to his family's care and although he has to make some changes to his lifestyle and take new medications he seems to be back to his old self.

Contrast that with your friend. He was only 45 and the picture of health. He had no history of any chest pains at all in the past and you had just gone out running with him the day before. Then out of nowhere it happened. One minute he was trimming his bushes and the next he was clutching his chest. His wife called 911 but as hard as the paramedics tried they couldn't revive him.

These are two extremes of the spectrum. What exactly happens when you have a heart attack and why do some people survive their heart attacks when others do not? Understanding how these things occur is not just an academic exercise. Knowing how a heart attack occurs can help us understand what we can do to prevent them.

While heart attacks seem to come on suddenly, they never come out of nowhere. The patient may or may not have had some warning signs but the process that leads to the heart attack started many years before the final event.

Studies done on soldiers killed in the Vietnam war showed that even at ages as young as 18 men had small cholesterol deposits in their arteries known as fatty streaks. This tells us that the process which ultimately leads to the formation of a dangerous cholesterol deposit most likely starts early and develops over many decades.

Deposits start to develop when LDL cholesterol particles (commonly referred to as "bad" cholesterol) migrate below the inner layers of the artery wall. The accumulation of these particles then attracts a type of white blood cell known as a macrophage. Macrophages engulf the LDL particles and then transform into foam cells. Over time the foam cells release their cholesterol which accumulates beneath the surface of the artery forming an atheroma. The atheroma is surrounded by an overgrowth of smooth muscle cells as well as foam cells and other inflammatory cells creating a complex structure we call a plaque.

Eventually the plaque may grow in size and the composition of the plaque can change. It may have a solid stable composition or alternatively it can become a very inflamed and unstable structure that might rupture at any time.

There is more than one way for a heart attack to occur. A person who has a history of chest pains that come on with exertion and then has a heart attack may have had a plaque that has gradually increased in size over years or even decades. As the opening through the artery becomes smaller and smaller the patient may start to notice chest pains when he engages in activities that make increased demands on the heart. The harder the heart works the more oxygenated blood it needs and if the artery becomes too narrow it can't deliver enough blood to meet the hearts needs. This type of pain is called angina. Initially the person may notice this only when he is climbing a steep hill or running but with time it might happen even when he is walking a few blocks on level ground. In severe cases patients may not be able to walk even a few steps to the bathroom without having angina symptoms.

If blood flow to an area of the heart is gradually reduced "collateral" arteries may form. These are additional blood vessels that grow into the area to make up for some of the loss of blood flow as the main artery became clogged. Collateral arteries usually don't provide as much blood flow as the original artery and they don't always form but when they do they are like natures own bypass operation just without the hospital stay or the bill. When the artery finally gets too narrow or closes completely there will be some damage to the heart muscle but it is often less severe than if the artery closes off suddenly and in most cases the patient will have had some warning because he most likely had angina for days, weeks, or years before the event. Approximately 25% of heart attacks occur this way.

If a patient is having chest pains when they exert themselves a doctor may order a stress test. If the stress test is abnormal they will then do an angiogram and if that shows a blockage the doctor may place a stent to open the narrowed area or in some cases bypass surgery may be required.

Many heart attacks do not happen through a gradual blockage of the artery though. Plaques are very complex structures. As we discussed above, the center is composed of cholesterol but there is a surrounding layer of smooth muscle cells and foam cells forming an overlying cap. In some cases the cap may be a stable structure but in other cases it's more fragile. Inflammation is thought to play an important role in the formation of plaques and the more inflammation there is the more unstable the plaque may be. In these cases the plaque may rupture and when it does the body treats it much the same way it treats a tear in the artery wall. The body's clotting system becomes activated and within minutes a clot forms at the site of the rupture. The clot grows and eventually obstructs the remaining opening in the artery leading to a heart attack. About 75% of heart attacks occur in this way.

In these cases there is often no warning because prior to the rupture there was good blood flow through the artery. In addition, because the blockage happened so suddenly there are usually no collateral arteries. For this reason the damage may be more severe, although the extent of damage also depends on the size of the artery that was blocked.

This may explain why patients can sometimes have a normal stress test one day and have a heart attack the next. No stress test can detect whether a plaque is unstable and about to rupture. They can only indirectly determine if the opening around the plaque is allowing enough blood to flow through the artery. A plaque that blocks 30-40% of the artery can go completely undetected but yet if it is unstable and ruptures it may result in a 100% blockage minutes later. CT angiograms ( also known as ultra-fast CT's or 64 slice CT's) and calcium scores all suffer from the same shortcoming. They are unable to detect small unstable plaques that are responsible for many of the sudden heart attacks we hear about.

As we saw above, survival after a heart attack may depend on how the heart attack occurs, but there are other factors that can affect the outcome also.

Heart attacks usually involve just a single artery that supplies a portion of the heart. The bigger the artery the more the damage when that artery is obstructed. If too large an area is damaged the heart does not have enough working muscle to pump blood effectively. When that happens even the parts of the heart with good arteries may not get enough blood flow and those areas will be damaged too. Within a matter of seconds or minutes the entire heart will be starved for oxygenated blood and may just stop pumping.

Sometimes even small arteries can cause fatal heart attacks. The heart is more than just a pump made of muscle. It also has an electrical system made up of specialized muscle cells that conduct electrical signals like wires. In order for a healthy heart to pump efficiently the muscle fibers that make up the top chambers need to contract in unison to force blood into the bottom chambers. After a brief delay the muscle fibers in the bottom chambers all have to contract together at the right time to force blood out of the heart to the lungs and the rest of the body. After another delay the whole process starts over. For this to work properly the hearts electrical system has to properly synchronize the entire sequence of events. If a heart attack occurs in a crucial spot it may damage the "wires" that conduct these signals around the heart. The heart will then enter a chaotic rhythm that doesn't allow it to pump blood effectively. Instead of a well coordinated muscular pump the heart may move like a disorganized bag of worms. There are several types of irregular heart beats (also called arrhythmias) that can develop such as Ventricular fibrillation, Ventricular tachycardia, Electrical mechanical dissociation, and eventually asystole. All of these can be fatal if not corrected quickly.

If the irregular rhythm is not corrected in a short period of time the lack of blood flow will lead to further and possibly irreversible damage. When doctors use a defibrillator to "shock" a patient that has gone into cardiac arrest they are attempting to correct one of these by "rebooting" the hearts electrical system in hopes that it will start back up in a normal rhythm.

Most people have heard the advice. Keep your cholesterol low, don't smoke, control high blood pressure, keep blood sugar under control and exercise regularly. All of these things do indeed affect your risk for a heart attack. Each one of these risk factors increases inflammation in the arterial wall which then promotes the formation of plaques. The more of these pro-inflammatory risk factors that you have the greater the chance that you will develop a problem. As bad as diabetes is, if you add high blood pressure and smoking to the mix the risk of heart disease will go up dramatically. The same is true for all the risk factors. The more you have the greater your risk.

Its thought that one of the ways that cholesterol medications reduce the risk of heart attacks is through an anti-inflammatory effect. Medications like Lipitor, Zocor, Crestor, and other such "statin" drugs will certainly lower bad cholesterol levels but other unrelated medications which also lower LDL do not reduce the risk of heart disease to the same degree as statins leading some to believe that these drugs may have a secondary anti-inflammatory effect in addition to their cholesterol lower benefits.

Genetics also plays a big role but unfortunately we can't do anything about this risk factor. For good or bad we don't have a choice about the parents we get. Luckily genetics is not as simple as "dad had a heart attack so you're going to have one". You're not a clone of your parents but a unique 50/50 combination of both of their genes. No matter which parent you seem to "take after" you are exactly half mom and half dad. While having a parent with heart disease does increase your risk no one can tell you what effect your unique mixture of genes will have on your health. Its possible you may have inherited some good genes from dad and not the bad ones or perhaps mom has a gene that counters the bad effects of a gene for heart disease that dad gave you. No one knows and no one can tell you. Youre best bet is to fix the things you have control over.

I have often heard people comment that " My uncle smoked his whole life and lived to be 90" or "My friend ran marathons and ate healthy and still had a heart attack when he was 45". This is true. No one knows for sure what their genetic makeup will lead to. Some of us are blessed and others are not but we have no way of knowing which camp we fall in to.

We have to keep in mind that there are no guarantees in life. Yes you could eat a Big Mac every day, smoke like a chimney and live to be 100. You could also hold onto a metal flag pole in a thunder storm and not get hit by lightening but how many times would you like to try that? Would you prefer to play a slot machine that gives you a 1 in 10 chance of winning or one that gives you a 4 in 10 chance? Staying healthy is not about guarantees, its about stacking the odds in your favor. We can't control our genes but virtually everything else IS under our control.

There are pages on this website that address most of the cardiac risk factors including diabetes, cholesterol, hypertension, smoking, and weight. If you want help with any of these problems take a look at the information on these links.

One last thing, patients often ask if they should have a stress test to prevent a possible heart attack. Someone who is having chest pains should certainly seek the advice of their doctor but if there are no symptoms then think about what we discussed above and read last weeks blog for a full explanation of why a stress test might not be a good idea.

As always if you have further questions please consult your physician.

This is a sad story but one I hear at least once or twice a year. Heart attacks or Myocardial Infarctions (MI's) are all too common. Although it may seem like cancer is public enemy number one, heart disease kills more people in the U.S. than all cancers combined. There were nearly 600,000 deaths in the U.S. due to heart disease in 2011. The incidence of heart attacks climb dramatically after age 65 but many adults will see their first friend have a heart attack when they are in their 40's.

Given the fact that most MI's in this age group occur with little warning it's understandable that these events strike fear in the hearts of men and women who begin to consider their own mortality. Its logical therefor to wonder whether a stress test might be a smart idea for those who want a bit of insurance against our number one killer. So what is a stress test and who should consider having one done?

There are several types of stress tests.

Standard Stress Test

Echo Stress test

Thallium ( or Nuclear) Stress test

All three types of stress tests require the individual to walk on a treadmill in order to "stress" the heart muscle. The only difference is in the way they evaluate how that stress is affecting the heart.

A standard stress test connects the patient to an EKG machine and looks for signs of stress in the hearts electrical activity. Heart muscle that is not getting enough blood flow may not conduct electrical impulses normally and this can show up in the EKG

An Echo Stress Test uses a sonogram ( echocardiogram) to examine how the heart muscle moves before and after the patient walks on the treadmill. Here we are looking for any sign that inadequate blood flow is causing some of the heart muscle to contract less effectively.

With a Thallium or Nuclear Stress Test the doctor injects the patient with a radioactive substance that is picked up in the heart. Areas of the heart with decreased blood flow will pick up less of the radioactive tracer. A detector is placed over the chest before and after the patient exercises on the treadmill and an image is created showing where the tracer was distributed. If there is an area that did not get as much tracer then this may indicate poor blood flow.

There is no "best" stress test. Each type of stress test has its advantages and disadvantages. Your doctor will determine which type is most appropriate for your situation if you need one of these.

Stress tests were originally designed to help doctors diagnose a patient who came in with complaints of chest pain. Many things can cause chest pain. Most of the time when a patient sees a doctor for chest pain the heart is not the source of the problem. So how does a doctor decide who has a heart problem and who doesn't? We needed a non-invasive way to determine which patients might require further more invasive testing and which ones could be managed conservatively. To fill this need the stress test was invented.

There is little controversy about the use of stress tests in situations where a patient is having chest pains, but what about someone who has just seen their friend have a heart attack and wants to see if he or she is at risk? Unfortunately this is one of those areas where what happens in real life doesn't match up well with what the facts and the science tell us.

Most patients who walk into their doctors office with this question will likely get an EKG and even if that is normal they will often be scheduled for a stress test to ease their concerns. The approach that many doctors take and patients demand is "better safe than sorry". No one wants a patient to walk out of their office with a life threatening condition when there might have been something they could have done about it. This argument ignores one important fact though. Stress tests are not harmless, and if there is a potential risk or side effect to a test then we need strong evidence that the good the test might do will outweigh the potential harm it can cause.

So what are the risks of having a stress test? All you do is walk on a treadmill right? How risky can that be? All good questions that deserve good answers.

The most obvious risk of the stress test is the treadmill itself. While it doesn't happen often, there are some patients every year who have a heart attack during the stress test. Its difficult to know in advance who this might happen to, but while its rare, the risk does exist.

The more important and more common risk is the one no one considers. What if the test results are wrong ? Stress tests like all tests are not perfect. There are false positives and false negatives.

A false negative is a test that says everything is fine when its not. The risk here is that the patient goes back to their bad habits and has a heart attack later that might not have occurred if they had not been reassured and the impact of their friends heart attack had stuck with them.

False positives are a much bigger concern There is no way to know if a stress test is a false positive unless we do further testing. With heart disease that often means doing an angiogram. During an angiogram a doctor threads a catheter through a large vein in the groin or the arm up to the heart and then injects die into the arteries of the heart so they show up on an x-ray imaging screen allowing the doctor to see if there is a blockage. Angiograms are relatively safe but there is always some risk when you do an invasive procedure. Those risks include hemorrhage, triggering an irregular heart beat ( arrhythmia), infection, kidney damage from the dye, and even sudden death. The overall rate of complications from cardiac catheterization is approximately 2-3% with a death rate of about 0.08%1. These numbers are low but they are not zero. When a patient's risk of heart disease is high ( someone with suspicious chest pain) the risk may be acceptable but if the person is healthy then the logic of going down this path needs to be reconsidered.

Ideally we would like some studies that followed asymptomatic men and women who had stress tests done and compared them to a similar group who did not undergo screening. If we compared these two groups we could then determine if screening reduced heart attack deaths and more importantly we would want to know if screening decreased the overall death rate. It does no good to reduce the deaths from heart attacks if the screening and subsequent treatments then increase deaths by some other route.

Unfortunately no such study has been done. The U.S Preventive Services Task Force reviewed this subject2 recently and was unable to find any studies that addressed this issue. Some studies have been done which examined how well stress tests predict cardiac risk compared with other methods but none of them examined whether adding stress test to the usual risk assessment method improved the outcome of patients.

Because of the lack evidence to support the benefits of routine stress testing the USPSTF as well as the American College of Cardiology and the American College of Physicians recommend against using stress testing in low risk asymptomatic individuals. For patients with moderate risk it is felt that there is insufficient evidence to make a recommendation for or against the use of stress testing.

Absolutely. Even though testing isn't the answer there is a lot we can do. It all comes down to controlling your risk factors. If you smoke, quit..NOW! If you have high cholesterol treat it with diet or medication to improve your numbers. If you have high blood pressure control that too. Get off the couch and exercise. Lose weight and reduce your alcohol consumption to one or two drinks per day. We know most of the risk factors for heart disease and although you can't pick your parents, or your sex, or stop the aging process, most of the other risk factors are things you can control.

Will controlling your risk factors guarantee that you won't have a heart attack? Of course not, but neither will a test. There are no guarantees in life, but if your real goal is to reduce the risk of a heart attack modifying your risk factors is the best way to improve your odds. Only you can do that by taking control of your risk factors before something happens.

Modifiable Heart Disease Risk Factors - Click on each one for assistance on controlling the risk factor.

]]>http://MDAskMe.com/blog/2013/09/10/who-should-get-a-stress-test-and-when#comments0Coffee: Elixer of Life or Poison? - What's the deal with all these conflicting studies?Mmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2013/08/28/coffee-elixer-of-life-or-poison-whats-the-deal-with-all-these-conflicting-studies
Wed, 28 Aug 2013 00:02:00 +0000http://MDAskMe.com/blog/2013/08/28/coffee-elixer-of-life-or-poison-whats-the-deal-with-all-these-conflicting-studiesIt seems like every day brings another study about something that will either help you live to 100 or kill you before you wake up tomorrow. The irony is that often the very thing that is supposed to deliver immortality on Monday becomes the agent of your early demise on Tuesday. Just this week a study was reported that linked the consumption of 4 or more cups of coffee per day and early death (Association of Coffee Consumption With All-Cause and Cardiovascular Disease Mortality) while another study 2 days later showed that coffee was able to improve a common condition known as fatty liver (High coffee intake is associated with lower grade nonalcoholic fatty liver disease). Why is it that there are so many conflicting reports? It makes you wonder if they are just playing games and if anyone really knows what they are talking about. While that is not true at all, the way in which these things are reported by the mass media sure makes the average person just want to throw up their hands and stop listening. In this article I will attempt to explain why this happens, why we shouldn't throw our hands up, and what we can do to sort out the real facts from the media hype.

There are several reasons for the confusion.

Comparing Apples and Oranges - Studies that seem to be looking at the same question may actually be looking at different things. The two coffee studies mentioned above are not actually examining the same question. One looked at lifespan and the other examined coffee's effect on a condition known as fatty liver. They really do not contradict each other since its possible that coffee could help someone's fatty liver but still cause an earlier death by negatively affecting some other organ system.

Studies are incorrectly interpreted - News reporters are not scientists and most of them with few exceptions have little or no scientific training. This often results in a situation where the reporter doesn't understand the story they are covering and they misinterpret the outcome of the study. In the example above several news reporters proclaimed that these two coffee studies contradicted each other and as I already pointed out that is not true.

Not all studies are equal - There are good studies and bad studies. Good studies require thoughtful design, take a lot of time, a lot of people, and a lot of money. Bad studies are much easier to do. Learning how to tell a good study from a bad one really isn't that difficult but reporters either don't understand the difference or don't take the time to examine this issue. I'll spend some time below going over the basic questions you should ask and the tools you can use to determine if the results of the latest study are valid before you give up your favorite beverage.

Science doesn't progress in a straight line - Even well done studies can't eliminate all confounding variables. We can't entirely eliminate genetic and environmental differences between two groups of test subjects that may throw off our results. We can try to compensate for those things but its not always possible to anticipate everything. For this reason any given study doesn't mean a lot and needs to be followed by additional studies done by other researchers. Retrospective studies need to be followed by double blind placebo controlled trials. Small pilot studies need to be followed by larger trials that may better eliminate "noise" in the data. This is the way science proceeds. One small study may show a benefit to a particular food, drug, or activity. A second larger study may not confirm that. A third study that is better designed and controlled may be done to clarify the conflicting results and this study may confirm or refute the original study. Sometimes a "Meta-analysis" will be done to combine the results of a group of studies in an attempt to gain the power of a much larger trial. The process proceeds until there is sufficient evidence to come to a conclusion with some reasonable level of certainty. This is the way scientific investigations proceed. It is not confusing to scientists who do this every day but it can be bewildering to the lay person, especially when the information is coming from a reporter who also doesn't understand how the scientific method works.

Science and medicine progress in a very deliberate fashion to find answers to questions we all want. They do this by using something called the scientific method. Its a method by which we ask a question, propose a possible explanation, and then devise experiments to prove or disprove our theory. As evidence mounts from those experiments the theory is either discarded or accepted depending on what the evidence shows. Its important to use the scientific method because it is the best and only way we have of finding answers that are not influenced by human biases, preconception, mysticism, and superstition. It is the best way we have to find out the truth about the word around us.

Along the way as we conduct studies to answer our questions we may find that these studies do not always give us the same answer. What we are witnessing in all the reports we hear is science in action. Scientists design studies in an attempt to answer questions we have but good studies are difficult to do. The investigator must design a study that removes as many conflicting variables as possible so that the only variable left is the one we are trying to examine. If you want to study the effect of coffee on life span the perfect study would look at thousands of identical twins. We would randomly assign one twin to drink coffee and the other to drink a placebo that looked smelled and tasted like coffee but wasn't coffee. Neither the investigators nor the participants would know who was drinking the placebo and who was drinking the real coffee during the trial period. Both groups of people would have identical lives and identical diets. Then they would follow these people over many decades to see what diseases they developed and at what age they died. Finally when the study was done the code would be broken and a analysis would be done to see if there was a statistically significant difference in the rate of disease and the life span of the two groups. By imposing all these limitations we can be sure that the only difference between the two groups is the consumption of coffee. In all other ways they would be nearly identical.

As you probably already figured out, doing a study that met all those criteria would be close to impossible. At the very least it would be very difficult, time consuming, and expensive. Its certainly wouldn't be easy to find a large number of identical twins who would agree to a lifelong study that imposed these restrictions.

So how do we ever set up a study that will answer our question? While its nearly impossible to put together a perfect study we can design a good study. The best way to do this is to design a large double blinded randomized placebo controlled study. Ideally in this type of study thousands of participants are enrolled and randomly assigned to one of two groups. One group is given a placebo and the other group gets the food or drug which we are trying to study. We use large numbers of people and randomly assign them to groups in order to increase the probability of getting two groups that are as similar as possible. If we allowed the doctors or the patients themselves to choose the group they wanted to be in then we may introduce unwanted variables into the study. If for example we were studying the effect of multivitamins on health and we allowed the participants to choose which group they wanted to join we might find that people who were more health conscious went into the vitamin group rather than the placebo group and this group might have other healthy habits like better diets and exercise routines which would artificially skew the results.

When we say a study is double blinded what we mean is that neither the doctors nor the subjects know who is getting what during the study. This is important because physicians and patients might report different responses to treatment if they think they are on the placebo or the real thing. Blinding the doctors and participants reduces the risk of biases being introduced into the results.

Small studies, studies that are not double blinded, or in which the participants were not randomly assigned should be viewed with some skepticism and should not be used for major life decisions. Although news program often fail to give these sort of details about the studies they report on its not hard to find them on the internet. I'll show you how I usually do this.

In the cases above I Googled the key words "coffee fatty liver" for one study and "coffee life span" for the other and clicked the News tab at the top since it had just been in the news. From this I was able to learn some basic details and the names of the journals the studies were in. Once I had this information I went to www.scholar.google.com and put in the name of the journal along with the same search terms I used above. That brought up the links to the actual articles. Its not necessary to read the entire article. Just read the few paragraphs in the abstract that have the methods and the conclusions and you will learn most of what you need to know about how the study was done and what the results were.

So far we have discussed double blind placebo controlled trials but many of the studies quoted in the news are not placebo controlled at all. Most of them are what we call "retrospective" or "population" studies. These studies are generally easier and cheaper to do but are of limited usefulness because we don't really control a variable and then observe the outcome. We simply ask a bunch of people what they eat for example and then ask them about their health problems. The study above linking coffee intake to an early demise was this sort of study. They asked people how much coffee they drank and then looked at the age when they died. People who drank more than 4 cups a day died at earlier ages. Media reporters then took this correlation ( more coffee linked to earlier deaths) and assumed causation ( more coffee was causing earlier deaths). While its tempting, its always dangerous and wrong to assign causation when all you have is a study showing correlation. There are other possible explanations for the outcome in a study like this. Its possible that coffee drinkers have a higher rate of other unhealthy habits and its those habits that increase the risk of premature death. For example coffee drinkers are more likely to be smokers and that may have lead to the early deaths rather than the coffee itself. Or perhaps patients with certain serious health problems drink more coffee in which case it would be the deadly disease that causes the increased coffee consumption and not the other way around. Its also possible that the correlation may have been a fluke and may not show up in other studies. ( For more on this see previous blog entry "What do Pirates and Global Warming have to do with Autism and Labor Induction?")

To summarize quickly:

When two studies seem to give conflicting results ask yourself if they are both looking at the same question.

Most media quoted studies are retrospective or population based studies that only show a link or correlation and should be viewed with a skeptical eye. If the reporter says a study showed "a link between" A and B this is most likely the case. Try to remember all the shortcomings associated with this sort of study and resist the temptation to assign cause and effect.

Double blinded placebo trials are the gold standard when it comes to studies, but bigger is always better. Studies on less than 100 people are small and should not be used alone for important decisions. Studies with thousands or tens of thousands of patients give much more reliable results.

No single study regardless of the type can provide a reliable answer to important questions. We should always wait to see if other researchers can reproduce the same results.

You don't need to do your own research on every study you hear about in the news. None of us have the time for that, but If the results of a study are important to you do your homework. Don't rely on the media reports since these are transmitted mostly by reporters who are not trained in the sciences and often misrepresent or don't understand the material they are presenting. Use PubMed or Google Scholar to find articles of interest.

There's no need to stop drinking coffee.

]]>http://MDAskMe.com/blog/2013/08/28/coffee-elixer-of-life-or-poison-whats-the-deal-with-all-these-conflicting-studies#comments0The PSA test - Should you be screened for prostate cancer on your next physical?Mmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2013/08/21/the-psa-test-should-you-be-screened-for-prostate-cancer-on-your-next-physical
Wed, 21 Aug 2013 12:00:00 +0000http://MDAskMe.com/blog/2013/08/21/the-psa-test-should-you-be-screened-for-prostate-cancer-on-your-next-physicalPSA is a protein that is produced in healthy prostate tissue. Prostate cancer cells also make PSA but on average they make more than healthy tissue does. For this reason it was thought that measuring PSA might be a reasonable way to screen for prostate cancer. If the level was higher than average then perhaps cancer was present. Using this reasoning the PSA test was developed and quickly became part of the routine blood work done on men when they had their physical exams.

While PSA testing became routine, until recently there were no studies that examined the outcome of men who had PSA's done. Yes we were detecting more prostate cancers and probably detecting them earlier but we had no evidence that it actually reduced death rates which is the only thing that really mattered. This is the reason for the current controversy. Two recently published studies have now provided evidence that there may be no survival advantage for men who have PSA's done regularly. As surprising as that seems there was some reason to expect these results.

One of the main issues with the PSA is the problem of false positives and false negatives. This isn't just a problem with the PSA. False positives ( a positive result in someone who does not have the disease) and false negatives ( a negative result in a person who does have the disease) are an unavoidable issue with nearly all tests. It has nothing to do with quality of the lab or the ability of the person performing the test. It is the nature of the tests itself. As stated above, even normal prostate tissue makes PSA but not everyone's prostate makes the same amount of PSA. Similarly not all prostate cancers produce high levels of PSA. If we were to measure the amount of PSA produced by a thousand healthy prostates in men 50-80 yrs old we would find a range from about 0-17 in 90% of men. If we measured the PSA in a thousand men with prostate cancer in the same age group we would find that 90% would have a PSA somewhere between 1 -613.

While the prostate cancer patients clearly have a higher PSA on average, we can see that there is a lot of overlap between the two groups. A PSA of 3.0 would be considered a "normal" test result but many patients with prostate cancer might have a PSA of 3.0 or less. Conversely a PSA above 4.0 would be considered elevated but as the graph above shows, there are a significant number of men with normal prostates who will have a PSA in that range.

False negatives can result in a missed diagnosis which is problematic if early detection has been proven to be beneficial. False positives are also a problem because they lead to more invasive and riskier tests such as biopsies. On occasion false positives may also result in unnecessary treatments which exposes the patient to additional risk.

False positive and negative test results are not the only problem with PSA testing though. Most people probably assume that any test which detects cancer earlier could only be a good thing. If there is an effective treatment that improves a patient's outcome when started early, then early detection should save lives. That is not always the case with cancer though. Contrary to popular belief early detection is not always helpful, in part because not all cancers are the same. Some cancers are harmless or nearly so. In those cases early detection won't improve the outcome because treatment is not necessary. Early detection may actually result in a worse outcome if unnecessary treatments are started which result in side effects or complications. Some prostate cancers fit into this category. Among men who live to age 80 ninety percent will develop prostate cancer. Most of them will die of old age though rather than their cancer.

On the other hand some cancers may be so aggressive that no treatment will help. Despite the large number of low grade prostate cancers, prostate cancer as a whole is still the second leading cause of cancer deaths in men. For men with very aggressive prostate cancer early detection may also offer no benefit and may be harmful.

There probably are some men who have a form of prostate cancer which can be treated effectively with early detection, but the question we need to answer is whether those cases balance the cases where men are treated unnecessarily and suffer side effects or even die from the treatment. This is the source of the current controversy.

Until recently there was insufficient evidence to draw a conclusion on the benefits and risks of PSA testing. Most physicians practiced under the assumption that early detection was likely to be beneficial and therefor they routinely ordered PSA tests on men between 40 and 75. What changed were recent studies done in the U.S. (PLCO trial) and Europe ( ERSPC study) and the subsequent recommendation by the U.S. Preventive Services Task Force (USPSTF). The USPSTF is an independent panel of physicians who are experts in primary care and preventive medicine. It is funded by the Department of Health and Human Services with the task of evaluating screening methods based on the best evidence available. Based on the PLCO and ERSPC studies as well as previous evidence the USPSTF came to the conclusion that the benefits of PSA screening did not outweigh the risks. The USPSTF uses a grading system for screening tests and gave the PSA test a grade of D which means "The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." It is generally recommended that physicians not use screening tests that have a D rating.

There are still some unanswered questions. We do not know whether PSA might still be useful in certain groups that are at higher risk for prostate cancer such as black men and men with a history of prostate cancer among first degree relatives ( father or brother). More studies need to be done to determine if these groups might benefit from PSA screening.

It is a good idea for all patients to discuss their individual situation with their personal physician before deciding whether to have a PSA test, but it appears that for the vast majority of men its best to refrain from using this test.

]]>http://MDAskMe.com/blog/2013/08/21/the-psa-test-should-you-be-screened-for-prostate-cancer-on-your-next-physical#comments0Self Monitoring of Blood Glucose (SMBG) - An unnecessary burden for most diabetics?Michael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2013/08/17/self-monitoring-of-blood-glucose-smbg-an-unnecessary-burden-for-most-diabetics
Sat, 17 Aug 2013 17:20:00 +0000http://MDAskMe.com/blog/2013/08/17/self-monitoring-of-blood-glucose-smbg-an-unnecessary-burden-for-most-diabeticsWe've all seen the TV commercials, the familiar grandfatherly actor and diabetic patient, Wilford Brimley sitting at home as he looks into the camera and encourages diabetics to "check your sugar and check it often" while he makes a cup of coffee. "Call XYZ medical supply now and get your test equipment at no cost to you" he says and then stirs in the cream and takes a sip. It sounds like a good idea doesn't it? After all its free, and obviously if you are a diabetic you want to keep your sugar under control. It would be easier to do that if you could measure your sugar level at home. In theory if you could easily check your sugar the instant feedback would tell you how your diet was working or whether the dose of your medication was correct. That's the theory, but theory and reality have a inconvenient habit of disagreeing with each other.

Home glucose monitoring machines have been available for several decades now but time and technology have made them increasingly smaller, more accurate, easier to use, and cheaper. Virtually anyone can be taught to use one of these machines at home to monitor their own sugar. Medicare as well as most insurance companies now pay for them. As these devices have become easier to obtain and operate, doctors have advised most of their diabetic patients to use them. It seemed a logical recommendation. Even today most people and many doctors believe this is good practice.

So should every diabetic check their sugars at home? The obvious answer is yes, but why would I have written this article if the obvious answer was the correct one? The correct answer is, it depends. It largely depends on whether you take insulin or not and for most type 2 diabetics who are not on insulin the correct answer may be no. Since most people with type 2 diabetes are not on insulin, the majority of diabetics may not need to monitor their blood sugar at home.

Whenever we recommend any sort of testing we always have to ask ourselves "How will this improve the patient's outcome?". The assumption with Self Monitoring of Blood Glucose (SMBG) is that a patient could use the information to improve their diet or exercise regimen. A little positive or negative feedback from these readings should over time give patients the kind of reinforcement we all respond to. A low reading after a work out would be like a pat on the back for a job well done, or if we were bad, a digital slap on the hand for the donut we knew we shouldn't have eaten. We might also suppose that medications could be adjusted based on these readings. In general people should be able to better fine tune their diet, exercise, and medications if they knew from hour to hour what their blood sugar was at any given time.

While this idea sounds reasonable there is an alternate view and there are good reasons to believe that testing may not help in the way that we would like. The difficulty with our theory is that we are assuming there is a simple connection between what we eat or the medication we take and what our sugar will be an hour or two later. In reality its much more complicated than that. Some of the difficulty derives from the fact that foods don't always cause blood sugar to peak at the same time. Some may cause a peak an hour later and others might peak 3 or 4 hours later. Absorption rates can also be affected by other foods that we've eaten at the same time so even the same food eaten by the same person may not always cause our blood sugar to peak the same way and at the same time. Exercise, stress, infections and many other things can affect blood sugar levels too so the same foods eaten under different circumstance may have different effects. Some of these things can be subtle and difficult to appreciate.

Its also difficult to adjust medication dose based on sugar readings. The affects of oral diabetic medications usually takes many hours to kick in and will vary from person to person in a way that is not as easy to predict as insulin. If your sugar is high in the morning its difficult to really know whether it was last night's medication dose or this morning's that was too low. If we then adjust our dose based on today's readings the effect may not show up until tomorrow and tomorrow will be a very different day.

Because of the delayed and unpredictable effect of food and oral medications it is difficult for a person to make sense of a blood sugar level. Its possible to eat a candy bar and sometimes still get a good reading or a stick of celery and find your reading is very high because the reading you take at 1pm may be affected by something you ate for breakfast or lunch or a combination of the two. If the morning sugar is low a patient might incorrectly assume they should skip their diabetes medication that morning even though the medicine may not have its maximal effect until late in the afternoon when their sugar would have been much higher.

Now we have two different and opposite theories about whether SMBG is useful for Type 2 diabetics. Which one is the right one? Theory is fine but what we truly want to know is what happens in the real world. Fortunately this has already been examined for us in a number of trials ( see references below). Some of these studies have used a test called a HGbA1c which is done at the doctors office. HgbA1c levels are used by physicians to determine what a patients average sugar has been over the previous 90 days. This test has been used for many years to more accurately assess the effectiveness of diabetes treatments. The advantage of this test is that it smooths out the up and down spikes in blood sugar readings that occur throughout the day. In a number of studies it has been shown that maintaining a HgbA1c below 7.0 reduces the risk of diabetes associated complications.

Most studies have shown that when Type 2 diabetics on oral medications do SMBG they do not have better HgbA1c compared to patients who never check their SMBG. In at least one study the HgbA1c's were actually higher in the patients who did regular SMBG. Additionally the use of SMBG has been found to increase psychological stress in patients.

It's not clear why this is the case but the issues mentioned above obviously play a part. It does little good to measure the effects of the last meal you ate if you don't know when those effects will actually occur. In fact measuring the SMBG might actually give someone the wrong idea. They may decide that diet really doesn't make that much of a difference since good foods sometimes resulted in higher sugars and bad foods sometimes gave them lower readings. They may also decide to skip their medication or lower the dose if their sugar reading is low when in fact that medication would not have maximally affected their blood sugar until 4 ,6, or 10 hours later. These are not just theoretical problems as I have seen these issues arise in my own patients, even in people who had been thoroughly educated in advance and warned not to do this.

Because of these issues, because of the current lack of evidence supporting any benefit from SMBG in this group of diabetics, and because of the possible harm that may come from SMBG, I do not encourage my patients to monitor their glucose at home in most cases unless they are taking insulin. I believe if we are going to ask patients to stick themselves with a sharp object daily we need good evidence that they are going to benefit from that process. Right now all the evidence says there is no benefit and there may be some harm that arises from this practice.

Of course each patient is unique and therefor anyone with questions should discuss their individual situation with their own doctor and review the risks and benefits before starting or stopping SMBG.

]]>http://MDAskMe.com/blog/2013/08/17/self-monitoring-of-blood-glucose-smbg-an-unnecessary-burden-for-most-diabetics#comments0Antioxidants - Not the saviors they are made out out to beMmelgar@doctormelgar.comMmelgar@doctormelgar.comhttp://MDAskMe.com/blog/2013/07/19/antioxidants-not-the-saviors-they-are-made-out-out-to-be
Fri, 19 Jul 2013 09:48:00 +0000http://MDAskMe.com/blog/2013/07/19/antioxidants-not-the-saviors-they-are-made-out-out-to-be

Worried about cancer? Antioxidants will prevent it. Want to halt the ravages of aging? Antioxidants will put an end to that too or so the claims go. Health food and vitamin companies, TV doctors and others have extolled the benefits of antioxidants for years creating a healthy demand for products containing antioxidants, but are the people who take them healthier for doing so?

The theory that antioxidants could prevent cancer and slow aging was developed more than 50 years ago based on some sound chemistry principals and some basic laboratory science. In a test tube antioxidants can neutralize something called free radicals. Free radicals are chemicals that react with proteins and DNA and cause damage to them. Stop DNA damage and you could prevent cancer and aging was the idea. The theory sounded good and initial studies in mice seemed to lend additional support.

The human body is far more complex than a test tube however, and as is often the case, ideas that look good in the lab don’t always lead to similar results in real human beings. Over the past 40 years numerous studies have been done using antioxidants in people with conflicting results. Some seemed to show a beneficial effect while others showed the exact opposite, but a 2007 analysis looked at 47 of the best trials and came to the conclusion that antioxidants actually led to a 5% increase in the rate of early death.

One large double blinded study published in1996 looked at 18,000 smokers to see if Beta carotene could reduce the risk of lung cancer. Beta-carotene is an antioxidant vitamin (Vitamin A). The study had to be stopped when it was found after 18 months that the risk of lung cancers was 28 percent higher and deaths were 17 percent higher in the group taking Beta-carotene.

So why all the excitement about antioxidants in the media and the health food store? Sometimes an idea sounds so good that no one checks the facts. Sometimes they don’t care or don’t want to know. In addition the media likes catch words that people can remember. Scientific sounding words and catch phrases also sell products. The supplement and health food industry has found the use of this term to be very profitable.

What should you do as an informed consumer who wants to stay healthy? Avoid taking antioxidant vitamins in amounts above the recommended daily allowance. Don’t fall for phrases like “superfood” or “antioxidants” when shopping for you and your family. Stick with a healthy diet which is high in fruits and vegetables and limit red meat consumption. Exercise regularly and drink alcohol only in moderation. Remember there are no magic words or short cuts to good health.

]]>Vitamin D - Fact and FictionMichael Melgar, MDMichael Melgar, MDEveryone from the your local newspaper to Dr. Oz have been pushing the public to increase their intake of Vitamin D. The claimed health benefits range from increased energy to cancer prevention and reductions in heart disease. While Vitamin D is [...]]]>http://MDAskMe.com/blog/2013/07/12/vitamin-d-fact-and-fiction
Fri, 12 Jul 2013 11:43:00 +0000http://MDAskMe.com/blog/2013/07/12/vitamin-d-fact-and-fictionEveryone from the your local newspaper to Dr. Oz have been pushing the public to increase their intake of Vitamin D. The claimed health benefits range from increased energy to cancer prevention and reductions in heart disease. While Vitamin D is an important nutrient some of its benefits are well documented and others are not. This newsletter will attempt to clarify these issues, but first a bit of the basics...

Where do we get Vitamin D?

Vitamin D is obtained by the body from several sources. We get some naturally from our food ( fatty fish, eggs), some from fortified foods (milk, bread, and cereals) and some from sun exposure.

How much Vitamin D do we need?

The USDA recently increased its recommendation for vitamin D. The recommended daily allowance for individuals from 1yr - 70 yrs old is 600 IU daily. Those older than 70 may need 800 IU daily.

Is it possible to get too much vitamin D?

Vitamin D is a fat soluble vitamin that deposits in the liver. Too much vitamin D can be toxic since the body can not easily get rid of excess amounts like it can with water soluble vitamins. The maximal amount of vitamin D that is considered unlikely to cause adverse effects is 2000 IU daily for individuals older than 1 year.

What are the known benefits of vitamin D?

Vitamin D has a number of well documented benefits. For many years it has been known that a deficiency in vitamin D can lead to a disease of the bones known as rickets. In addition to its importance in bone formation, Vitamin D is used by the body’s immune system and muscles. One of Vitamin D’s most important functions is in the absorption and regulation of Calcium levels which is why it’s so important to bone development.

If all of this is old news, why all the recent attention to vitamin D?

In the past few years there have been a number of studies suggesting that vitamin D might be associated with reduced rates of some types of cancer and heart disease. While these studies have been intriguing they have not been strong studies and results have been inconsistent.

Most of the studies involving Vitamin D have been epidemiological studies. For example, scientists noticed that people living in lower latitudes where it is sunnier where less likely to have colon cancer. They postulated that these people had higher sun exposure and higher vitamin D levels and therefore Vitamin D might explain the difference. The problem with studies like this is that there may be many other differences between these groups of people like diet, race, ethnic background, availability of heath care etc. which may have lead to the difference in cancer rates.

The most reliable type of study is a double blind placebo controlled study. This sort of study is the best way to identify whether there is a real correlation between two factors such as Vitamin D intake and cancer. To date no well designed placebo controlled studies have been done that show a reliable link between increased vitamin D intake and cancer reduction, and NONE have looked at the benefits or risks of measuring and then supplementing low vitamin D levels

Unfortunately there has been a rush to judgment on this issue within the media and even among some in the medical community in an effort to be on the leading edge. Many have begun telling people to have their vitamin D levels checked and have even recommended taking very large doses of Vitamin D if the levels are low. At the moment there is no evidence that this approach is beneficial or even safe.

As a patient what should I do?

For now the only thing that any adult should do is to make sure that they are getting no less than 600 IU/day of vitamin D and no more than 2,000 IU. Efforts to measure Vitamin D levels are not recommended and efforts to supplement low levels with high doses of vitamin D may be misguided and potentially harmful.

Please visit the link below for more information on Vitamin D from the National Institutes of Health.

]]>Natural - What does that word mean?Michael Melgar, MDMichael Melgar, MDhttp://MDAskMe.com/blog/2013/07/11/natural-what-does-that-word-mean
Thu, 11 Jul 2013 21:54:00 +0000http://MDAskMe.com/blog/2013/07/11/natural-what-does-that-word-mean
What does it really mean when we say something is natural? It seems like an easy question but the truth is that there is no agreed upon definition for this word. In fact the FDA does not even have an official definition of the word natural. When it comes to food, their policy has simply been not to object to the use of the word as long as “The food does not contain added color, artificial flavors, or synthetic substances.” The public assumes that natural means wholesome and unprocessed but that may not be true and in fact there are no guidelines restricting companies from extensively processing the products they label as natural. When the word natural is applied to remedies or supplements that supposedly have some health promoting quality the use of the word natural seems to have no real rules at all.

It's interesting to examine the assumptions we make about the word natural. Are natural products really safer or better for us and why? When you really look into it, the fact is that nature has no soft spot in it's heart for human beings or their health. Lots of so called natural substances are extremely harmful. One of the most potent cancer causing chemicals on the face of the earth is a naturally occurring substance called Aflatoxin that is produced by certain fungi. Poison Ivy is natural, and Arsenic is natural too but most people wouldn't consider ingesting either of them.

Where does the idea come from that natural products are safe? Most likely it derives from two sources. There is a trend in our crazy scary modern society to believe that things were simpler and safer when we all lived on a farm and our food came directly out of the ground on our own land. Its a rosy if not completely accurate view of the past that strikes a chord with many people. That's only part of the explanation though. The misperception that natural means safe also comes from the simple observation that most people who use natural remedies seem to have no ill side effects. The perception is also due in no small part to marketing agencies and manufacturers who have discovered the public is willing to pay more for products marketed as natural if the public believes these products are safer than the traditional alternatives.

Is there anything wrong with this thinking and why shouldn't we use natural products? The best answer to that question is that while there may be nothing wrong with foods that meet the vague definition of natural, there may also be nothing special about them either. To begin with, natural foods often cost a lot more than other foods and despite their wide and varied claims, there is little if any scientific evidence to show that natural or organic foods are any healthier than those grown with synthetic fertilizers and pesticides. In fact some of the worst food born e.coli outbreaks in the country have been caused by organically grown “natural” foods.

Although the worst thing about natural foods may be the added cost and wasted money, natural remedies are another story. The only reason most people seem to have no ill effects from these remedies is simply because most of these products have no effects at all.. good or bad. The word natural seems to carry an almost magical promise of a cure with no side effects. Unfortunately there is nothing magical about natural remedies. Remedies for any illness can only work if they have a biological effect inside the body, and any substance that has biological effects is by definition a drug whether they call it that or not. As such it is just as likely to have unforeseen side effects whether the product is natural or man made. Most natural products are completely harmless only because they are also completely useless. Its important to keep in mind that the reason we know about most drug side effects is because there is a system in place whereby side effects can be reported and tracked. No such system exists for natural remedies and supplements so similar side effects when they do exist generally go unreported. Even so a number of natural products have been removed from the market over the years because of harmful and even fatal side effects, but because these products are not monitored problems are not noticed unless they are extreme or effect a large number of people. It is also important to note that there is no requirement for natural remedies to prove that they are effective. The law does prohibit these remedies from claiming they cure or treat a disease or illness but skilful lawyers often craft the wording on these packages so it sounds like it can cure something even if a close reading of the claims technically abides by the law. A company can not claim its supplement cures the enlargement of the prostate seen in older men known as BPH but it can list all of the symptoms of BPH and then claim the product promotes "prostate health" so the consumer comes away with the impression that it will treat BPH. They can do this despite a complete lack of evidence that the product does anything at all.

To answer the original question, what does natural mean? While the FDA and the manufacturers seem to be having a lot of difficulty defining the word, all you have to do is look at how they are using it and the definition becomes pretty clear. Natural means untested. It also means unproven, but the one thing it doesn't necessarily mean is safe. There are no magic words or shortcuts to good health. The best way to stay healthy is to eat more fruits and vegetables, cut down on red meat, sugars and starches, wash your food, cook it well, and use medicines and remedies that have been tested thoroughly instead of those which have little to offer except a meaningless word on the package.